What’s In A Due Date? {Part II}

The first part of this series was dedicated to how due dates are calculated and what they really mean. Hopefully, this information was helpful in helping my readers to realize that an estimated due date, or EDD, is just that: an estimate. An estimate with quite a bit of range, actually. In this second part, I want to talk briefly about the “expiration date” mentality; that is, once you hit your due date, you are now “overdue”.

Babies are not library books nor cottage cheese; they are not “overdue” nor do they “expire”. In a majority of cases, having a pregnancy that goes beyond the 40-week mark is completely healthy and normal, yet doctors still tend to want to start talking induction around this time, which, for many women, just causes more stress, anxiety, or worry. So what is truly evidence-based? When is going past your due date normal, and when (if at any time) is it truly necessary to induce labor?

As I mentioned in my previous post, 60% of normal, healthy pregnancies naturally occur within a week on either side of their due date, with a whopping 90% of births occurring within two weeks. Basically, instead of a “due date”, we really have more of a due month!

“I believe that women and their babies would be better served if the forty-two-week limit in state midwife rules and regulations was changed to forty-three weeks -or, better yet, dropped. There are almost always clear symptoms when a baby is in danger from staying in the womb too long.” – Ina May Gaskin, Ina May’s Guide to Childbirth

The main, valid concern for a longer pregnancy revolves around what doctors call “post-mature syndrome”, also known as “Clifford’s Syndrome” or “Ballantyne-Runge Syndrome”. Keep in mind that “post-term” has been defined as AFTER 42 weeks. Two main symptoms of this syndrome include a decrease in the amount of amniotic fluid or a change in the baby’s heart rate, both of which may indicate a failing placenta – which is the sac which provides nourishment and oxygen to the baby before he or she is born. Because the placenta is failing to provide adequate nutrients for the baby, he or she may be at an increased risk for developing asphyxia (impaired breathing) and hypoglycemia (low blood sugar). Since babies are more developed in utero, there is also a greater chance they may pass meconium (their first bowel movement) before birth, therefore the risk of meconium aspiration (aka inhaling the meconium) is greater. However, there are also conflicting beliefs about how dangerous meconium in the womb actually is, with some birth professionals even asserting it can be a normal part of birth and as long as thick particles aren’t present and baby’s heart rate is fine, then the birth can continue to progress normally. This article has a very educated and interesting take on meconium in utero.

Most women are concerned with the risk of fetal macrosomnia, otherwise known as having a big baby. Fetal macrosomnia is defined as when a baby weighs over 8 pounds 13 ounces, and is found in about 9% of births worldwide. While the diagnosis can come with some risks to mom and baby, it is again important to remember that each pregnancy is different and each birth should be viewed as individual. A small-framed woman who develops gestational diabetes will most likely be at a higher risk for complications than a taller, broad woman who just naturally has bigger babies. Other considerations to remember include that ultrasound weights can be inaccurate (one study found overestimation of baby’s weight to be inaccurate almost 10% of the time, leading to an over 20% increase in cesarean sections) and birthing positions can make a big difference – squatting alone can open the pelvis by up to 30%, as opposed to semi-reclining, which is still the norm in the majority of hospital births.

Another listed risk of a post-term baby is stillbirth. A study in Canada identified the rate of stillbirth amongst 654,621 babies between 1992 and 1994, finding that there is a slightly higher risk of stillbirth after 43 weeks. However, this study also showed that the rate of stillbirth at slightly longer gestations was lower than that of slightly shorter gestations (.34% versus .41%).

Wen, S.W. Joseph, K.S. Kramer, M.S. Demissie, K. Oppenheimer, L. Liston, R. & Allen, A. (2001) Recent Trends in Fetal and Infant Oucomes Following Post-term Pregnancies. Fetal and Infant Mortality Study Group, Canadian Perinatal Surveillance System, Chronic Diseases in Canada, 22(1).

Wen, S.W. Joseph, K.S. Kramer, M.S. Demissie, K. Oppenheimer, L. Liston, R. & Allen, A. (2001) Recent Trends in Fetal and Infant Oucomes Following Post-term Pregnancies. Fetal and Infant Mortality Study Group, Canadian Perinatal Surveillance System, Chronic Diseases in Canada, 22(1).

An upside to our use of technology is that these risks are usually easily identified by stress-tests and/or ultrasounds –  easy ways to determine if your baby is at risk for any of these complications. Then, together you and your provider can determine which risk is greater: the risk of a post-term baby or the risk of the induction itself. I would personally be concerned by any doctor who refused to perform any of these tests and tried to schedule an induction based on date alone – whether it’s one day after your EDD, or one week, or even longer.

“I had agreed to schedule an induction mainly because the doctor was crazy pushy and did a lot of “your baby is going to die if you go past 41 weeks”… I don’t remember if he used those exact words but I do remember him saying that the longer I went over my due date, the more dangerous it was and he was worried about fluid levels or something. I had an ultrasound two days before I gave birth and everything was fine though.” – A mother who ended up going into labor naturally at 41 weeks (right before her scheduled induction) and gave birth to a perfectly healthy baby boy

It kind of makes you wonder: if doctors aren’t willing to provide solid evidence that a baby or a mother is, indeed, in danger, why are they so apt to induce in the first place? Convenience? It is ironic that the CDC acknowledges that “As the use of medical interventions for childbirth (i.e., induction of labor and cesarean delivery) has increased during the last few decades, an increasing proportion of deliveries occur during regular daytime hours“.

Or, could it be more doctors have a fear of malpractice? After all, it may be harder to defend against a claim that a doctor didn’t do enough as opposed to doing too much. I think, so often, we want to put these doctors up on a pedestal and assume they have all the answers and can do no wrong – until they do, and then, in the spirit of our country, we sue the heck out of them. Honestly, I can’t really blame the doctors who practice conservatively under a fear of malpractice. However, I do think us women also have to realize that we are accountable for our own births, including the provider we choose and the procedures that we let them perform.

I’ve talked to many mothers wishing to avoid a procedure, whether it be something “small” like cervical checks or cord-clamping or something “big” like an induction or cesarean section. They come to me asking, “What do I say? How do I convince them?” And I tell you – you can do your homework, you can spend hours researching and compiling solid and valid evidence-based information, you can be ready for the debate of the century…. but will you convince them? Doubtful. Sometimes, the most powerful word you can say is just simply, “No”. Being confident in your decision is the most important thing, and in the end, it is your birth: not theirs. Hopefully, you have chosen a provider who you feel comfortable enough with, who will respect your decisions, and who will be upfront and honest with you, as opposed to using blanket fear tactics. Unfortunately, this may not be true for every situation (for example, income restrictions or limited options in certain areas), and in that case, I truly think actions speak louder than words anyway.

“The evidence about the risks of “prolonged pregnancy” shows that there is nothing to be gained by chemical induction before 41.5 weeks. Even after 41.5 weeks, the few studies we have show that about five hundred women must be induced in order to prevent one perinatal death” – Ina May Gaskin, Ina May’s Guide To Childbirth

Hopefully, these two posts have been helpful for my readers in determining when a real risk to a “late” baby is present and when a late pregnancy is perfectly normal. The most current statistics I could find in the United States showed an induction rate of 33.6% in “late-term pregnancies” (41 weeks) and 27.7% in “post-term pregnancies” (42+ weeks) in 2012, and the cesarean rate in 2014 was 32.2%, yet The World Health Organization recommends that the caesarean section rate should not be higher than 10% to 15%.” We are looking at over 20% of births that are potentially unnecessary and invasive surgeries – over 790,900 women a year. I can’t help but feel that our current induction methods have some sort of correlation with our current surgery rates, especially as I hear more and more birth stories that begin with inductions and end with a c-section. My question is: how many of these inductions occurred unnecessarily, purely because of a due date and not because of any real risk to mother or child? Maybe someday I will be able to find more research, studies, and statistics on this topic, but until those are available, we are left relying not only on doctor recommendation, but also on common sense, anecdotal evidence, and instinct.

Trust your body. Trust your baby. Trust God.

And remember: a due date is not an expiration date. Sometimes the risk of an induction may be greater than the risk of a “late” baby, especially if the mother and baby are not showing any signs of distress. And that, I believe, is a whole other topic for a future post.

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