Advertisement
JOGC

No. 214-Guidelines for the Management of Pregnancy at 41+0 to 42+0 Weeks

  • Martina Delaney
    Affiliations
    St. John's, NL
    Search for articles by this author
  • Anne Roggensack
    Correspondence
    Corresponding Author: Dr. Anne Roggensack, University of Calgary, Calgary, AB.
    Affiliations
    Calgary, AB
    Search for articles by this author
  • Author Footnotes
    ∗ Clinical Practice Obstetrics Committee: Dean C. Leduc, MD (Chair), Ottawa, ON; Charlotte Ballermann, MD, Edmonton, AB; Anne Biringer, MD, Toronto, ON; Martina Delaney, MD, St. John's, NL; Loraine Dontigny, MD, Lasalle, QC; Thomas P. Gleason, MD, Edmonton, AB; Lily Shek-Yn Lee, RN, Vancouver, BC; Marie-Jocelyne Martel, MD, Saskatoon, SK; Valérin Morin, MD, Cap-Rouge, QC; Joshua Nathan Polsky, MD, Windsor, ON; Carol Rowntree, MD, Sundre, AB; Debra-Jo Shepherd, MD, Regina, SK; Kathi Wilson, RM, Ilderton, ON. Disclosure statements have been received from all members of the committee.

      Abstract

      Objective

      To provide evidence-based guidelines for the management of pregnancy at 41+0 to 42+0 weeks.

      Outcomes

      Reduction of perinatal mortality associated with Caesarean section at 41+0 to 42+0 weeks of pregnancy.

      Evidence

      The Medline database, the Cochrane Library, and the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists, were searched for English language articles published between 1966 and March 2007, using the following key words: prolonged pregnancy, post-term pregnancy, and postdates pregnancy. The quality of evidence was evaluated and recommendations were made according to guidelines developed by the Canadian Task Force on Preventive Health Care.

      Recommendations

      • 1.
        First trimester ultrasound should be offered, ideally between 11 and 14 weeks, to all women, as it is a more accurate assessment of gestational age than last menstrual period with fewer pregnancies prolonged past 41+0 weeks (I-A).
      • 2.
        If there is a difference of greater than 5 days between gestational age dated using the last menstrual period and first trimester ultrasound, the estimated date of delivery should be adjusted as per the first trimester ultrasound (I-A).
      • 3.
        If there is a difference of greater than 10 days between gestational age dated using the last menstrual period and second trimester ultrasound, the estimated date of delivery should be adjusted as per the second trimester ultrasound (I-A).
      • 4.
        When there has been both a first and second trimester ultrasound, gestational age should be determined by the earliest ultrasound (I-A).
      • 5.
        Women should be offered the option of membrane sweeping commencing at 38 to 41 weeks, following a discussion of risks and benefits (I-A).
      • 6.
        Women should be offered induction at 41+0 to 42+0 weeks, as the present evidence reveals a decrease in perinatal mortality without increased risk of Caesarean section (I-A).
      • 7.
        Antenatal testing used in the monitoring of the 41- to 42-week pregnancy should include at least a non-stress test and an assessment of amniotic fluid volume (I-A).
      • 8.
        Each obstetrical department should establish guidelines dependent on local resources for scheduling of labour induction (I-A).

      Key Words

      Abbreviations:

      CI (confidence interval), CRL (crown–rump length), EDC (estimated date of conception), LMP (last menstrual period), NST (non-stress test), OR (odds ratio), PMR (perinatal mortality rate), RCT (randomized controlled trial), RR (relative risk)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Obstetrics and Gynaecology Canada
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

      1. International Statistical Classification of Diseases and Related Health Problems, 10th revision. World Health Organization, Geneva (CH)2006
        • Mary Hannah M.
        • and the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada
        Post-term pregnancy. SOGC Clinical Practice Guideline No. 15, March 1997.
        (Available at:) (Accessed July 9, 2008)
        • Sue-A-Quan A.K.
        • Hannah M.E.
        • Cohen M.M.
        • et al.
        Effect of labour induction on rates of stillbirth and cesarean section in post-term pregnancies.
        CMAJ. 1999; 160: 1145-1149
        • McClure Browne J.C.
        Postmaturity.
        Am J Obstet Gynecol. 1963; 85: 573-582
        • Votta R.A.
        • Cibils L.A.
        Active management of prolonged pregnancy.
        Am J Obstet Gynecol. 1993; 168: 557-563
        • Evans T.N.
        • Koeff S.T.
        • Morley G.W.
        Fetal effects of prolonged pregnancy.
        Am J Obstet Gynecol. 1963; 85: 701-709
        • Eden R.D.
        • Seifert L.S.
        • Winegar A.
        • et al.
        Perinatal characteristics of uncomplicated postdates pregnancies.
        Obstet Gynecol. 1987; 69: 296-299
        • Feldman G.B.
        Prospective risk of stillbirth.
        Obstet Gynecol. 1992; 79: 547-553
        • Smith G.C.
        Life-table analysis of the risk of perinatal death at term and post term in singleton pregnancies.
        Am J Obstet Gynecol. 2001; 184: 489-496
        • Hilder L.
        • Costeloe K.
        • Thilaganathan B.
        Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality.
        Br J Obstet Gynecol. 1998; 105: 169-173
        • Cotzias C.S.
        • Paterson-Brown S.
        • Fisk N.
        Prospective risk of unexplained stillbirth in singleton pregnancies at term: population based analysis.
        Br Med Journal. 1999; 319: 287-288
        • Usher R.H.
        • Boyd M.E.
        • McLean F.H.
        • et al.
        Assessment of fetal risk in postdate pregnancies.
        Am J Obstet Gynecol. 1988; 158: 259-264
        • Treger M.
        • Hallak M.
        • Silberstein T.
        • et al.
        Post-term pregnancy: should induction of labor be considered before 42 weeks?.
        J Matern Fetal Med. 2002; 11: 50-53
        • Olesen A.W.
        • Westergaard J.G.
        • Olsen J.
        Perinatal and maternal complications related to postterm delivery: a national register-based study, 1978–1993.
        Am J Obstet Gynecol. 2003; 189: 222-227
        • Kitlinski M.L.
        • Kallen K.
        • Marsal K.
        • et al.
        Gestational age-dependent reference values for pH in umbilical cord arterial blood at term.
        Obstet Gynecol. 2003; 102: 338-345
        • Woolf S.H.
        • Battista R.N.
        • Angerson G.M.
        • et al.
        Canadian Task Force on Preventive Health Care. New grades for recommendations from the Canadian Task Force on Preventive Health Care.
        CMAJ. 2003; 169: 207-208
        • Savitz D.
        • Terry J.W.
        • Dole N.
        • et al.
        Comparison of pregnancy dating by LMP, ultrasound scanning, and their combination.
        Am J Obstet Gynecol. 2002; 187: 1660-1666
        • Boyce A.
        • Mayaux M.
        • Schwartz D.
        Classical and true gestational postmaturity.
        Am J Obstet Gynecol. 1970; 106: 676-679
        • Saito M.
        • Keijiro Y.
        • Akinori H.
        • et al.
        Time of ovulation and prolonged pregnancy.
        Am J Obstet Gynecol. 1976; 112: 31-38
        • Gardosi J.
        • Vanner T.
        • Francis A.
        Gestational age and induction of labour for prolonged pregnancy.
        Br J Obstet Gynaecol. 1997; 104: 792-797
        • Hadlock F.P.
        • Deter R.L.
        • Harrist R.B.
        • et al.
        Computer-assisted analysis of fetal age in the third trimester using multiple fetal growth parameters.
        J Clin Ultrasound. 1988; 11: 313-316
        • Tunon K.
        • Eik-Nes S.
        • Grotten P.
        Fetal outcome in pregnancies defined as postterm according to the LMP estimate, but not according to the ultrasound estimate.
        Ultrasound Obstet Gynecol. 1999; 14: 12-16
        • Waldenstrom U.
        • Axelsson O.
        • Nilsson S.
        • et al.
        Effects of routine one-stage ultrasound screening in pregnancy: a randomized controlled trial.
        Lancet. 1988; 2: 585-588
        • Saari-Kemppainen A.
        • Karjalainen O.
        • Ylostalo P.
        • et al.
        Ultrasound screening and perinatal mortality: controlled trial of systematic one-stage screening in pregnancy. The Helsinki Ultrasound Trial.
        Lancet. 1990; 336: 387-391
        • Ewigman B.G.
        • Crane J.P.
        • Frigoletto F.D.
        • et al.
        Effect of prenatal ultrasound screening on perinatal outcome.
        N Engl J Med. 1993; 329: 821-827
        • Kramer M.S.
        • McLean F.
        • Boyd M.E.
        • et al.
        The validity of gestational age estimation by menstrual dating in term, preterm, and postterm gestations.
        JAMA. 1988; 260: 3306-3308
        • Blondel B.
        • Morin I.
        • Platt R.W.
        • et al.
        Algorithms for combining menstrual and ultrasound estimates of gestational age: consequences for rates of preterm and postterm birth.
        BJOG. 2002; 109: 718-720
        • Bukowski R.
        • Saade G.
        • Malone F.
        • et al.
        A decrease in postdates pregnancies in an additional benefit of first trimester screening for aneuploidy.
        Am J Obstet Gynecol. 2001; 185: S148
        • Bennett K.A.
        • Crane J.M.
        • O'Shea P.
        • et al.
        First trimester ultrasound screening is effective in reducing postterm induction rates: a randomized controlled trial.
        Am J Obstet Gynecol. 2004; 190: 1077-1081
        • Crowley P.
        Interventions for preventing or improving the outcome of delivery at or beyond term.
        (The Cochrane Database of Systematic Reviews)1997 (Issue 1)
        • Welch K.K.
        • Malone F.D.
        Nuchal translucency-based screening.
        Clin Obstet Gynecol. 2003; 46: 909-922
        • D'Alton M.
        • Cleary-Goldman J.
        First and second trimester evaluation of risk for fetal aneuploidy: the secondary outcomes of the FASTER Trial.
        Sem Perinatol. 2005; 29: 240-246
        • Taipale P.
        • Ammala M.
        • Salonen R.
        • et al.
        Learning curve in ultrasonographic screening for selected fetal structural anomalies in early pregnancy.
        Obstet Gynecol. 2003; 101: 273-278
        • Mitchell M.D.
        • Flint A.P.
        • Bibby J.
        • et al.
        Rapid increase in plasma prostaglandin concentrations after vaginal examination and amniotomy.
        Br Med J. 1977; 2: 1183-1185
        • McColgin S.W.
        • Bennet W.A.
        • Roach H.
        • et al.
        Parturitional factors associated with membrane stripping.
        Am J Obstet Gynecol. 1993; 169: 71-77
        • Netta D.
        • Visintainer P.
        • Bayliss P.
        Does cervical membrane stripping increase maternal colonization of group B streptococcus?.
        Am J Obstet Gynecol. 2002; 187: S221
        • Boulvain M.
        • Irion O.
        • Marcoux S.
        • et al.
        Sweeping the membranes to prevent post-term pregnancy and to induce labour: a systematic review.
        Br J Obstet Gynaecol. 1999; 106: 481-485
        • Boulvain M.
        • Irion O.
        Stripping/sweeping the membranes for inducing or preventing post-term pregnancy.
        Cochrane Database Syst Rev. 2004; : CD001328
        • Foong L.C.
        • Vanaja K.
        • Tan G.
        • et al.
        Membrane sweeping in conjunction with induction.
        Obstet Gynecol. 2000; 96: 539-542
        • Doany W.
        • McCarthy J.
        Outpatient management of the uncomplicated postdate pregnancy with intravaginal prostaglandin E2 gel and membrane stripping.
        J Matern Fetal Med. 1997; 6: 71-78
        • Wiriyasirizvaj B.
        • Vutyavanich T.
        • Ruangsri R.
        A randomized controlled trial of membrane stripping at term to promote labour.
        Obstet Gynecol. 1996; 87: 767-770
        • Goldenberg M.
        • Dulitzky M.
        • Feldman B.
        • et al.
        Stretching of the cervix and stripping of the membranes at term: a randomized controlled study.
        Eur J Obstet Gynecol Reprod Biol. 1996; 66: 129-132
        • el-Torkey M.
        • Grant J.M.
        Sweeping of the membranes is an effective method of induction of labour in prolonged pregnancy.
        Br J Obstet Gynaecol. 1992; 99: 455-458
        • Cammu H.
        • Haitsma V.
        Sweeping of the membranes at 39 weeks in nulliparous women: a randomized controlled trial.
        Br J Obstet Gynaecol. 1998; 105: 41-44
        • Berghella V.
        • Rogers R.A.
        • Lescale K.
        Stripping of membranes as a safe method to reduce prolonged pregnancies.
        Obstet Gynecol. 1996; 87: 927-931
        • Wong S.F.
        • Hui S.K.
        • Choi H.
        • et al.
        Sweeping of membranes in formal induction of labour.
        BJOG. 2002; 109: 632-635
        • Crane J.
        • Bennett K.
        • Young D.
        • et al.
        The effectiveness of sweeping membranes at term: a randomized trial.
        Obstet Gynecol. 1997; 89: 586-590
        • de Miranda E.
        • van der Bom J.G.
        • Bonsel G.J.
        • et al.
        Membrane sweeping and prevention of post-term pregnancy in low-risk pregnancies: a randomized controlled trial.
        BJOG. 2006; 113: 402-408
        • Henry G.R.
        A controlled trial of surgical induction of labor and amnioscopy in the management of prolonged pregnancy.
        J Obstet Gynaecol Br Cmwlth. 1969; 76: 795-798
        • Suikkari Am
        • Jalkanen M.
        • Heiskala H.
        • et al.
        Prolonged pregnancy: induction or observation.
        Acta Obstet Gynecol Scand Suppl. 1983; 116: 58
        • Katz Z.
        • Yemini M.
        • Lancet M.
        • et al.
        Non-aggressive management of post-date pregnancies.
        Eur J Obstet Gynecol Reprod Biol. 1983; 15: 71-79
        • Cardozo L.
        • Fysh J.
        • Pearce J.M.
        Prolonged pregnancy: the management debate.
        Br Med J. 1986; 293: 1059-1063
        • Witter F.R.
        • Weitz C.M.
        A randomized trial of induction at 42 weeks of gestation vs. expectant management for postdates pregnancies.
        Am J Perinatol. 1987; 4: 206-211
        • Augensen K.
        • Bergsjo P.
        • Eikeland T.
        • et al.
        Randomised comparison of early versus late induction of in post-term pregnancy.
        Br Med J. 1987; 294: 1192-1195
        • Dyson D.C.
        • Miller P.D.
        • Armstrong M.A.
        Management of prolonged pregnancy: Induction of labor versus antepartum testing.
        Am J Obstet Gynecol. 1987; 156: 928-934
        • Martin J.M.
        • Sessums J.K.
        • Howard P.
        • et al.
        Alternative approaches to the management of gravidas with prolonged-postterm- postdate pregnancies.
        J Miss State Med Assoc. 1989; 30: 105-111
        • Bergsjo P.
        • Gui-dan H.
        • Su-qin Y.
        • et al.
        Comparison of induced versus non-induced labor in post-term pregnancy.
        Acta Obstet Gynecol Scand. 1989; 68: 683-687
        • Heden L.
        • Ingemarsson I.
        • Ahlstrom H.
        • et al.
        Induction of labor versus conservative management in prolonged pregnancy: controlled study.
        Int J Fetomaternal Med. 1991; 4: 231-236
        • Herabutya Y.
        • Prasertsawat P.O.
        • Tongyai T.
        • et al.
        Prolonged pregnancy: the management dilemma.
        Int J Gynecol Obstet. 1992; 37: 253-258
        • Hannah M.E.
        • Hannah W.J.
        • Hellamn J.
        • et al.
        Willan and the Canadian Multicenter post-term pregnancy trial group. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial.
        N Engl J Med. 1992; 326: 1587-1592
      2. The national institute of child health and human development network of maternal-fetal medicine units. A clinical trial of induction of labor versus expectant management in postterm pregnancy.
        Am J Obstet Gynecol. 1994; 170: 716-723
        • Roach V.J.
        • Rogers M.S.
        Pregnancy outcome beyond 41 weeks gestation.
        Int J Gynecol Obstet. 1997; 59: 19-24
        • James C.
        • George S.S.
        • Guanekar N.
        • et al.
        Management of prolonged pregnancy: A randomized trial of induction and antepartum foetal monitoring.
        Nat J India. 2001; 14: 270-273
        • Chanrachakul B.
        • Herabutya Y.
        Postterm with favorable cervix: is induction necessary?.
        Eur J Obstet Gynecol Reprod Biol. 2003; 106: 154-157
        • Ocon L.
        • Hurtado R.
        • Coteron J.J.
        • et al.
        Prolonged Pregnancy: procedure guidelines.
        Progresos de Obstetricia y Ginecologia. 1997; 40: 101-106
      3. Chakravarti S, Goenka B. Conservative policy of induction of labor in uncomplicated postdated pregnancies. XVI FIGO World Congress of Obstetrics and Gynecology; 2000 Sept 3–8; Washington DC, USA (Book 3). 2000:62.

        • Gelisen O.
        • Caliskan E.
        • Dilbaz S.
        • et al.
        Induction of labor with three different techniques at 41 weeks of gestation or spontaneous follow-up until 42 weeks in women with definitely unfavorable cervical scores.
        Eur J Obstet Gynecol Reprod Biol. 2005; 120: 164-169
        • Heimstad R.
        • Skogvoll E.
        • Mattson L.
        • et al.
        Induction of labor or serial antenatal fetal monitoring in postterm pregnancy.
        Obstet Gynecol. 2007; 109: 609-617
        • Hannah M.E.
        Postterm pregnancy: should all women have labour induced? review of the literature.
        Fetal and Maternal Medicine Review. 1993; 5: 3-17
        • Sanchez-Ramos L.
        • Olivier F.
        • Delke I.
        • et al.
        Labor induction versus expectant management for postterm pregnancies: a systematic review with meta-analysis.
        Obstet Gynecol. 2003; 101: 1312-1318
        • Gulmezoglu A.M.
        • Crowther C.A.
        • Middleton P.
        Induction of labour for improving birth outcomes for women at or beyond term.
        Cochrane Database Syst Rev. 2006 Oct; 18: CD004945
        • Menticoglou S.M.
        • Hall P.H.
        Routine induction of labour at 41 weeks gestation: nonsensus consensus.
        Br J Obstet Gynaecol. 2002; 109: 485-491
        • Alfirevic Z.
        • Walkinshaw S.A.
        A randomised controlled trial of simple compared with complex antenatal fetal monitoring after 42 weeks of gestation.
        Br J Obstet Gynaecol. 1995; 102: 638-643
        • Guidetti D.A.
        • Divon M.Y.
        • Langer O.
        Postdate fetal surveillance: is 41 weeks too early?.
        Am J Obstet Gynecol. 1989; 161: 91-93
        • Bochner C.J.
        • Williams J.
        • Castro L.
        • et al.
        The efficacy of starting postterm antenatal testing at 41 weeks as compared with 42 weeks of gestational age.
        Am J Obstet Gynecol. 1988; 159: 550-554
        • American College of Obstetricians and Gynecologists
        Practice Bulletin.
        (Management of postterm pregnancy. No. 55)2004
        • Royal College of Obstetricians and Gynecologists
        Induction of labour. Evidence based clinical Guideline No. 9.
        RCOG Press, LondonJune 2001 (Available at:) (Accessed July 9, 2008)