Are you really "overdue"?

Original Post Available HERE:
http://www.facebook.com/note.php?note_id=152890514765371&id=110067179067769

Are you really "overdue"?


The chances are that you will not actually reach 42 weeks anyway, as when the date of conception is known, this is quite unusual. Many pregnancies which are thought to be "overdue" are just inaccurately dated.
Standard pregnancy dating based on your last period date (LMP) is only accurate if you have a 28-day cycle and you ovulated on day 14. If your cycles are sometimes longer than this then there is a good chance that your due date is actually later than the 'standard' one.
Conception has to happen in the 24 hours after ovulation - you cannot conceive before your egg has been released, but the egg dies if unfertilized 12-24 hours later. So your most accurate way of dating the pregnancy is knowing when you ovulated. This is not necessarily on a day when you had sex; sperm can survive for up to four days, possibly longer, so the intercourse which resulted in conception could have occurred several days before the actual conception. If you have been charting your cycles or practising natural family planning you will know all about this - if not, see the links on dating your pregnancy for more info.
One very thorough study of over 24,000 pregnant women in the UK who had dating scans which were compared with their LMP date [1], found that:
"Most pregnancies undergoing post-term induction are not post-term when assessed by ultrasound dates"
A review of the study noted that:
"If we look at how many women end up going 2 weeks over their due date, it is 9.5% according to dating by LMP but only 1.5% when dated by scan. This suggests that the dating of pregnancy by LMP tends to overestimate the gestation. Therefore if scan information is available, it is preferable to use this for dating a pregnancy (presuming it was carried out during the first half of pregnancy, when dating is most accurate)." [2]
Ultrasound scans for dating are pretty accurate in the first trimester, but get less and less accurate as time goes on.
Sometimes a scan will suggest that your due date is actually later than the LMP date, but the revised date may not have been entered on your notes as your 'new' due date. Check that any recommendations for induction are based on the most accurate assessment of your due date, not on LMP dating.
Even if you are genuinely post-dates, your chances of going into labour naturally increase with every day which passes:
"of women at 40 weeks, 65% labour spontaneously within the next week. Of those at 10 days over their dates, 60% will enter spontaneous labour within the next 3 days." [2]


But what if you really are "overdue"?

It is undeniable that the rate of stillbirths and neonatal deaths does rise as pregnancy becomes more and more prolonged. However, many of these deaths are due to congenital abnormalities, or occur in babies with intra-uterine growth restriction. It is not clear how much the death rate rises for normal babies who do not show any signs of being growth-restricted. It can be alarming to hear that the death rate for pregnancies over 42 weeks doubles, but it is perhaps more informative to let people know the figures rather than the relative chance. Some sources suggest that the death rate for apparently normal babies, ie those without detected abnormalities, may rise from around 1 in 1,000 to 2 in 1,000. See the US Midwife Archive detailed paper on post-dates pregnancy.


Can you be induced at home?

The methods of induction of labour normally offered by medical staff are membrane sweeping, prostaglandin gel or pessaries which are inserted into the vagina (or occasionally given orally), artificial rupture of the membranes ('breaking the waters'), and an oxytocin drip, which is given in the synthetic forms of Syntocinon (in the UK) and Pitocin (in the USA).
Membrane sweeping can be performed at home or in an antenatal clinic, and there is no reason why you cannot have a home birth after it has been carried out. However, it is not as effective at inducing labour as other methods.
Artificial Rupture of Membranes is sometimes carried out to induce labour at home, but nowadays this is uncommon as it can place the baby under stress and increases the risk of infection. Used carefully, though, it can be highly successful - for instance see Danielle's story. For more about breaking the waters in general, see the UK Midwifery Archives (www.radmid.demon.co.uk/arm.htm)
Induction with drugs, using prostaglandins or oxytocin drips, is not carried out at home as it significantly increases the risk of foetal distress, and can cause hyperstimulation of the uterus. It is usual to have continuous electronic foetal monitoring after these drugs are given in hospital, to watch for signs of distress. Many women also find contractions significantly more painful after drug induction and an epidural may be needed.
There are also various Do-It-Yourself methods of inducing labour which you can try at home.


What if you refuse induction of labour?

It is, of course, your right to refuse any medical treatment which is proposed, including induction of labour. It is up to you to make the decision which is right for your family. The vast majority of women who decline induction of labour will go on to have healthy babies. See for example the stories about "Ten Month Mamas" on birthlove.com.
You can ask for monitoring to check your baby's wellbeing, instead of choosing induction. There is a very small risk of foetal death occurring suddenly despite reassuring monitoring, but this can happen at any stage of pregnancy - and as the sources above show, it is extremely rare. Some women feel that it is not appropriate to accept induction on the basis of a one-in-a-thousand risk.
The UK's National Institute of Clinical Excellence and the Royal College of Obstetricians and Gynaecologists offer this information to pregnant women and their families [3]:


If your pregnancy is more than 41 weeks

Even if you have had a healthy trouble free pregnancy, you should be offered induction of labour after 41 weeks because from this stage the risk of your baby developing health problems increases. An induction because you are overdue does not increase the chance of you needing a caesarean section.
If you choose not to be induced at this stage then from 42 weeks you should be offered:
Twice weekly checks of your baby's heartbeat using a piece of equipment called an electronic fetal heart rate monitor.
A single ultrasound test to check the depth of amniotic fluid (or "waters") surrounding your baby.
An ultrasound scan in early pregnancy (before 20 weeks) can help to determine your baby's due date more accurately. This reduces your chances of unnecessary induction.
If you find yourself under pressure to accept induction at 42 weeks and you are not happy with this, then it may help to discuss these guidelines with your doctor or midwives; the Royal College of Obstetricians and Gynaecologists (RCOG) does make clear that monitoring beyond 42 weeks is an alternative to induction.[4]
The full Guidelines on Induction of Labour from the RCOG emphasise that:
Women must be able to make informed choices regarding their care or treatment via access to evidence based information. These choices should be recognised by health professionals as an integral part of the process. [5]
You can still have a home birth if your pregnancy is over 42 weeks gestation. This may involve some negotiation with your caregivers as different midwives and obstetricians have different views on the risks of post-dates pregnancy. Some are relaxed about it while others will be very concerned. However, the bottom line is that nobody can force you to go into hospital to give birth. See 'Birth Stories about long pregnancies' for some case studies of women who have decided to stay home.
If you are told that you 'cannot' have a home birth beyond a certain point in your pregnancy, it may be worth taking a "we'll cross that bridge if we come to it" approach. There is little point in putting yourself in stressful situations and having conflicts with your midwives, when the situation may well not arise. Such debates have their place, but maybe campaigning is better carried out when you are not at the end of your pregnancy! However, if you do find yourself 'overdue' and your midwives say that you 'cannot' have a home birth, you may have little choice but to argue your corner.
One approach which many people find helpful is to write a polite, no-nonsense letter to the Supervisor of Midwives. If you put things in writing then your position is made clear and it will usually be taken seriously. Here is an example of a letter you might use:
Dear Supervisor of Midwives,
I am expecting a baby, and my due date was ........ I would like to inform you that I am continuing with my plans to give birth at home. I appreciate that your advice is to give birth in hospital post 42 weeks, but I have made an informed decision to decline this offer of hospital admission at present.
I will of course transfer to hospital if my baby's condition, or my own, makes it necessary, but for the time being I would appreciate your continued support of my informed decision.
Many thanks for your help,
Yours....
If you find yourself under continuing pressure to accept hospital admission, you may need to be more forceful. Contact the Association for Improvements in the Maternity Services (www.aims.org.uk) for advice as they are very experienced in helping women in this situation.


Meconium-Stained Liquor

One issue to be aware of if you do stay at home for a post-dates pregnancy is meconium-stained liquor. This is where the baby has passed meconium (done its first poo) while still in your womb, and when your waters break, they are found to be stained brown or green. It becomes more and more likely as pregnancy progresses beyond 40 weeks. Many health authorities will request that you transfer to hospital whenever meconium-staining is found as it can be an indicator that the baby is, or has been, in distress. It can also lead to Meconium Aspiration Syndrome, a dangerous condition which can occur if the baby breathes in meconium while still inside the womb.
In post-term pregnancies, many midwives believe that passing meconium does not necessarily indicate that the baby has been in distress, as it is also often simply an indicator that the baby's gut is mature. It is sometimes said that meconium-stained liquor before 40 weeks is far more significant than it is in post-dates pregnancy, and for this reason some mothers choose not to transfer to hospital for meconium staining if the meconium is not thick. It is a difficult issue and controversial issue, and one which you are more likely to have to deal with in a post-dates pregnancy. I am still searching for good sources of information on this, but have been doing so for five years without much success!


Membrane Sweeping

The RCOG Guidelines on Induction of Labour emphasise that a membrane sweep should be offered before other forms of induction are considered. Sweeping the membranes does not seem to put babies under any additional stress, so there is no reason why you should not have a home birth after your membranes have been swept. Here is some info on membrane sweeping from the NICE/RCOG patient information document on induction of labour:

Membrane sweeping

This has been shown to increase the chances of labour starting naturally within the next 48 hours and can reduce the need for other methods of induction of labour.
Membrane sweeping involves your midwife or doctor placing a finger just inside your cervix and making a circular, sweeping movement to separate the membranes from the cervix. It can be carried out at home, at an outpatient appointment or in hospital.
If you have agreed to induction of labour, you should be offered membrane sweeping before other methods are used. The procedure may cause some discomfort or bleeding, but will not cause any harm to your baby and it will not increase the chance of you or your baby getting an infection. Membrane sweeping is not recommended if your membranes have ruptured (waters broken).


Possible Disadvantages

Women's experiences of membrane sweeping vary widely. Some find it mildly uncomfortable, while others find it extremely painful.
There is a risk that your waters could be accidentally broken, which then increases the risk of your baby contracting an infection. Because of this, if your waters break, you will normally be put under pressure to give birth within 96 hours (NICE guidelines) or less, with induction offered if your labour does not progress that fast naturally. You can, of course, refuse such induction, but you'd need to consider your individual infection risk first.
There is a risk that a weak, stop-start labour could be triggered, because your body or baby was not really ready for labour - see the discussion about DIY induction methods, below. If this happens, you may find yourself exhausted in the early stages of labour, and transfer to hospital for an epidural for rest, and to have your labour artificially speeded up. I am not aware of any research on the rates of induction or augmentation of labour after membrane sweeping, so this is speculation rather than evidence-based.


DIY alternatives to induction

If you are desperate to see your baby, or are finding it hard to decline offers of hospital induction, then you may be considering ways to bring on labour yourself. There are plenty of links and suggestions on the UK Midwifery archives page on complementary therapies.
It might be worth thinking through exactly you do not want induction in hospital. If you would not accept medical treatment to bring on labour, what is different about using complementary therapies? Fine, if your intention is just to avoid hospital - but if you are concerned about interfering with your body's ability to give birth, then DIY methods might not be right for you.
If your baby is not ready to be born, in a difficult position, or your body is not ready to go into labour, then DIY induction might bring on a weak pre-labour which peters out. If this happens, and you have already informed your midwives, then you might find yourself under pressure to go into hospital for acceleration of labour, or you might find yourself tired out by the time true labour begins.
DIY labour induction has worked well for many women, and may work for you - but do be aware that it is an intervention, albeit usually a gentler one than hospital induction, and it may well alter the course of your labour.


Is your baby in the right position?

It may be that there is a very good reason why you have not gone into spontaneous labour so far. If your baby is not in a good position to pass through your pelvis, then it may not be exerting enough pressure on your cervix to trigger labour. The ideal position for labour is with the occiput - the back of the baby's head - towards the front ('occiput anterior' or OA). The position is normally further described according to which side the baby is leaning towards, ie Left Occiput Anterior or LOA when the occiput and back is towards your left side, which is most common, and Right Occiput Anterior or ROA when the baby's occiput and back is towards your right side.
As well as the baby's position being 'anterior', the baby's chin should be tucked down on its chest so that the occiput is nearest to your cervix. This ensures that the baby's head has the best chance of fitting through your pelvis. Babies normally try to get themselves into this 'ideal' position for birth, but sometimes they may take their time doing so.
If your baby is in the occiput posterior position (facing outwards, its back against your spine) then you may not go into spontaneous labour until it has moved around to face the other way. There is a very good reason for this - labour with the baby in the posterior position may be harder than usual for first-time mothers (although often no problem if this is not your first baby), and vaginal birth is sometimes impossible as the baby's head may get stuck as it attempts to turn in your pelvis. For more information, see 'Get your baby lined up'.
Similarly, if your baby is positioned so that its face, forehead or ear is nearest to your cervix at the moment, then vaginal birth could be very difficult or impossible, and labour will often not start on its own until the baby has moved.
If you are induced when the baby is malpresented, then the result could be a very difficult labour or a caesarean section. This is one of the reasons why many women prefer to avoid induction - we usually just don't know why labour hasn't started yet, and there may be a very good reason for it.
If you are considering induction, you can first of all ask your midwife to check your baby's position, and do so yourself (see 'Get your baby lined up'). It is not possible to identify all malpresentations before labour, and some babies start labour in a good position and then decide to move to a worse one! However, you should at least be able to check whether your baby is anterior or posterior.


ITS YOUR CHOICE

Essentially, its youre body, and your choice. Arming yourself with as many of the facts and research as possible can help you make an informed decision, and make the right choice for you and your baby. It can also make those awkward discussions with medical care-givers A LOT EASIER when you know the facts risks and benefits of what you are proposing.