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POSTDATE: WHEN AND HOW TO INDUCE?

F. Facchinetti , V. Vaccaro
Unit of Gynecology and Obstetrics, Mother-Infant Department, University of Modena and Reggio Emilia, Modena,
Italy

Complications of Postdate pregnancy: A prolonged pregnancy is commonly defined as a


pregnancy that has extended to or beyond 42 weeks of gestation (294 days, or estimated
1,2
date of delivery [EDD] plus 14 days) . It is not synonymous with post-maturity, which is a
3,4
clinical syndrome thought to be a consequence of a failing placental function .
5,6
Approximately 5 to 10 percent of all pregnancies continue to at least 42 weeks of gestation .
Most cases of postdate pregnancies result from a prolongation of gestation. Other cases
result from inaccurate dating criteria. Although the last menstrual period (LMP) has been
traditionally used to calculate the EDD, many inaccuracies exist using this method in women
who have irregular cycles, have been on recent hormonal birth control, or who have first
trimester bleeding. Ultrasonographic dating early in pregnancy can improve the reliability of
the EDD, reduce the incidence of pregnancies diagnosed as post-term and minimize
7,8
unnecessary interventions .
So the risk of adverse sequelae may be reduced by making an accurate assessment of
gestational age and diagnosis of post-term gestation, as well as recognition and management
of risk factors. Risk factors for postdate pregnancy may include primiparity and previous postterm pregnancies. Placental sulfatase deficiency, fetal anencephaly, and male sex have been
9
associated with prolongation of pregnancies , and genetic predisposition also may play a
10,11
role
.
Post-term pregnancies are at increased risk for numerous adverse outcomes including both
5,12-17
maternal and perinatal complications (Table 1)
.
st
The main argument against a policy of routine induction of labor around 41 week has been
that induction increases the rate of cesarean delivery without decreasing maternal and/or
21-24
neonatal morbidity
. Some of the studies that failed to show a reduction in fetal/neonatal
morbidity were diluted by poorly dated pregnancies that were not necessarily postterm. In
addition, the potential for increasing the risk for cesarean delivery with a failed induction is far
17
less likely in the era of safe and effective cervical ripening agents .
Table 1: Risks Associated with Postdate Pregnancy
Maternal risks
Emergency
cesarean
delivery (doubled)
Cephalopelvic
disproportion
Cervical rupture
Labor Dystocia
Large fetus
Shoulder Dystocia
Severe perineal injury
Puerperal infection
Postpartum hemorrhage
Psychological
complications

Neonatal risks
Stillbirth
Neonatal death
Meconium aspiration
Intrauterine growth restriction
Intrapartum asphyxia
Macrosomia
Brachial plexus injuries
Bone fracture
Low umbilical artery pH levels
at delivery
Low 5-minute Apgare scores
Dysmaturity syndrome
Peripheral nerve paralysis
Pneumonia
Septicaemia

A retrospective review of 18,055 singleton pregnancies, has found no differences in cesarean


25
delivery rates in women entering spontaneous labor and those who had induced labor .
Moreover, two prospective randomized studies have found no increase in the rate of
cesarean delivery in patients who were randomized to routine induction of labor. In fact, more
cesarean deliveries were performed in the noninduction groups, and the most frequent
indication was fetal distress. The neonatal outcomes were similar in both the routine induction
and noninduction groups. All 2 trials concluded that the incidence of adverse perinatal
outcomes in low-risk pregnancies at or after 41 weeks' gestation is very low with either
26,27
induction or expectant management
.
Further data suggest that induction may actually be more beneficial than expectant
management in patients at 41 weeks of gestation. A study has shown that the policy of
inducing labour at 41 weeks and 4 days (291 days of gestation) in uncomplicated pregnancies

is justified because when the gestational age is more than 41 weeks and 4 days, the
incidence of meconium staining of amniotic fluid and evidence of uteroplacental insufficiency
28
increases significantly . A meta-analysis reviewed 11 trials and concluded that a policy of
routine induction had a lower rate of perinatal morbidity and cesarean delivery, demonstrating
18,29
both fetal and maternal benefit compared to expectant management
. In addition, a recent
systematic review with meta-analysis concluded that a policy of labor induction at 41 weeks
gestation for otherwise uncomplicated singleton pregnancies reduces cesarean delivery rates
6,30
without compromising perinatal outcomes . Furthermore, the option of elective cesarean
section should be considered, particularly with an unfavorable cervix, advanced maternal
31
age . The estimation of fetal weight does not have predictive role since the poor accuracy of
32
routine fetal ultrasound, at term .
In summary, routine induction at 41 weeks' gestation does not increase the cesarean delivery
rate, and may decrease it, without negatively affecting perinatal morbidity or mortality. In fact,
there may be both maternal and neonatal benefits to a policy of routine induction of labor in
well-dated low-risk pregnancies at 41 weeks' gestation. However, a policy of routine induction
17
at 40 weeks' has few benefits .
ACOG has stated that it is reasonable to inducing labor in post-term pregnancies in which the
cervix is favorable because the risk of failed induction and subsequent cesarean delivery is
low. In low-risk post-term women with unfavourable cervices, both labour induction and
expectant management are associated with low complications rates and good perinatal
outcomes; there does appear to be a slight advantage to labour induction using cervicalripening agents. If there is evidence of fetal compromise or oligohydramnios, delivery should
be affected and prostaglandin can be used in post-term pregnancies to promote cervical
7
ripening and induce labour .
Guidelines, however, often differ from clinical practice. A study has shown that although most
contemporary practicing obstetricians manage post-term pregnancies according to recent
ACOG educational materials with regard to antenatal fetal surveillance and methods of
induction, the majority induce patients with singleton post-term pregnancies at 41 weeks
33
gestation rather than waiting until 42 weeks gestation .
Expectant Management: Antepartum fetal surveillance: Despite a lack of evidence that
34-36
monitoring improves perinatal outcome
, when expectant management is chosen, fetal
17
monitoring must be performed . ACOG states that it is reasonable to begin antepartum
7
testing after 41 weeks (287 days) of gestation , although many obstetric care providers will
th
start fetal testing around 280 day of gestation, being women further examined at 287-289
19
and 291 days of gestation . Low-risk women are generally monitored with maternal
measurement of fetal movement, Non StressTest (NST) and the evaluation of Amniotic Fluid
Index (AFI) which is obtained with the summation of the largest vertical pocket in 4 quadrants
19,37
. Other options include modified biophysical profile (BPP) (a combination of NST
(Table 2)
and AFI), full BPP (NST, AFI, fetal tone, movement and breathing), Doppler velocimetry of
umbilical artery and the computerized fetal heart rate analysis whose diagnostic ability has
38,41
been recently ascertained in the identification of patients at risk of fetal distress in labour
.
Table 2: Nonstress Test Criteria
Result
Reactive

Non reactive
(abnormal)

Criteria
In a 20-minute period, two or
more fetal heart rate
accelerations of at lest 15
beats per minute above the
baseline heart rate.
Each acceleration lasts at least
15 seconds.
Fetal movement may or may
not be discernible by the
patient.
No fetal heart rate
accelerations over a 40-minute
period.

Ultrasound Estimates of Amniotic Fluid Volume


Measurement
Oligohydramnios
technique
Amniotic fluid index
0 to 5 cm
Single deepest
0 to 2 cm
pocket
Two-diameter pocket 0 to 15 cm
Normal
5.1 to 25
cm
2.1 to 8 cm
15.1 to 50
cm

Polyhydramnios
>25 cm
>8 cm
>50 cm

Active Management: induction of labour: Postdate pregnancy is the single and more common
cause of induction of labour. In addition to Oxytocin, there are some non-pharmacological
methods used to induce labour, including: * Stripping the membranes * Cervix mechanical
40,41
.
dilation * Manual nipple stimulation * Amniotomy
Membrane stripping has poor efficacy and mechanical dilatation with Foley catheter as well
as nipple stimulation are scarcely utilized despite some proof of efficacy. Amniotomy is, on
the contrary, well indicated at a significant cervical dilatation (at least >3cm), being a
manoeuvre that should be done before Oxytocin infusion. However, the success of induction
is strictly dependent on cervical ripening. Therefore, before actual induction is begun, patients
should undergo Bishop Scoring in order to assess the readiness of the cervix using the 10point system gwhich grade 5 factors: dilation; degree of effacement; application of the
41
presenting part; consistence of cervix; cervical position .
In women presenting with very unfavourable cervix (Bishop<5), Prostaglandins are the best
42
agents actually licensed for ripening the cervix and Dinoprostone, a prostaglandin E
analogue, has proven to induce both cervical softening and shortening, often activating labour
43
itself . The availability of Prostaglandins in the last 15-20 years made possible induction of
labour then otherwise would have an high rate of failure, with the sole use of oxytocin.
.According to recent studies, the pre-induction cervical ripening with dinoprostone slowrelease vaginal insert is associated with a very high rate of women undergoing a vaginal
delivery within 24 hours with a shorter admission compared to 0.5 mg dinoprostone intra19,43
.
cervical gel (Fig.1).
Another prostaglandin has been shown to be an effective agent for cervical ripening and
44,45
labour induction, i.e., Misoprostol
. A recent study has shown that Misoprostol vaginal
46
inserts successfully induced labour in pregnant parous women at term . However,
Misoprostol has no indication for such employment: because it is an off-label drug, it should
be managed with caution.
FIG.1 Outcomes of labour induction according to treatment group. A: Women entering in
labour within 24-h (p<0.01); B: Vaginal delivery<12-h (p<0.01); C: Vaginal delivery<24-h
(p<0.01); D: Oxytocin induction (p<0.01); E: Caesarean section.
60%
50%

Dinoprostone Vaginal
Insert

40%
30%
20%

Dinoprostone Intra
Cervical gel

10%
0%
A

Conclusions: It is now well assessed that pregnancy prolongation beyond 42 weeks is an


hazard for the foetus. The advent of perinatal medicine and its access by the majority of
women then reduced the rate of pregnancy reaching such a high gestational age. In our
region, Emilia-Romagna, an industrialized country in the north of Italy, the possibility for a
correct dating of pregnancy is available to everybody and the rate of post-date in 2005 was

2.4%. I would suggest that the rate of post-date become a marker of quality of a Perinatal
47
Unit, considering every delivery occurring after 294 days an adverse outcome.
As far as policies, however, nothing could be concluded on the two contrasting attitudes, i.e.
th
expectant management till 290-92 days or elective induction of labour at 287 day. Since the
evidence based medicine approach do not allow any definite conclusion in this respect, the
choice on when to induce should be balanced also considering the women orientation and the
anxiety of the dyad patient-obstetrician.
Certainly, prostaglandins are by far the best pharmacological tool for managing the induction
of labour. They provide a high rate of success and few adverse events have been reported
with their correct use, also in high-risk categories like women already having one
hysterotomy. Other agents are under evaluation in order to find a true cervical ripener, i.e. a
substance that allow collagen disaggregation, increases water and hyaluronic acid content
modifying the anatomic structure without affecting miometrial contractility. Nitric oxide donors
would have such a profile and their use together with classical prostaglandins is now under
48,49
.
clinical evaluation, even with contrasting results
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