Management of Late Term Pregnancy
12/1/2018 - Jennifer Salcedo, MD, MPH, MPP
Mentor: Tony Ogburn, MD
Editor: Chesney Thompson, MD
Late term pregnancy refers to pregnancies from 41 0/7 through 41 6/7 weeks gestation. Compared to full term pregnancy (39 0/7 - 40 6/7 weeks), late term and postterm pregnancy (42 0/7 weeks and beyond) are associated with increased risks of perinatal morbidities such as oligohydramnios, meconium aspiration syndrome, macrosomia, shoulder dystocia, neonatal seizures, neonatal intensive care unit admission, perinatal mortality, and decreased Apgar scores. As pregnancy advances beyond full term, maternal risks of cesarean delivery, operative vaginal delivery, postpartum hemorrhage, infection, severe perineal laceration, and hypertensive disorders of pregnancy increase.
Induction of labor in women without contraindications to vaginal delivery should be considered in the late term period and is recommended in the postterm period. Membrane sweeping is associated with decreased risk of late term pregnancy and can be considered for women at full term. Membrane sweeping is performed in the setting of a dilated cervix and involves digitally separating the membranes from the lower uterine segment. Women should be counseled that the procedure may be associated with discomfort and vaginal bleeding. The risks of membrane sweeping in women with group B streptococcus colonization are not clearly defined.
For women who choose expectant management over induction, antepartum fetal surveillance with NST, biophysical profile (BPP), modified BPP, or contraction stress test should be considered starting at 41 weeks EGA. Modified BPP with measurement of the deepest vertical pocket (DVP) may decrease intervention compared to the amniotic fluid index (AFI). Induction is recommended for oligohydramnios or non-reassuring surveillance.
Confirmation of gestational age should be established for appropriate management, as LMP alone may not provide an accurate EDC, and elective delivery is not recommended in suboptimally dated pregnancies. For women who desire a trial of labor after cesarean (TOLAC), reduced maternal and perinatal risks of induction must be weighed against the small increased risk of uterine rupture and TOLAC failure compared to awaiting spontaneous labor. Decisions regarding induction timing should be undertaken in a process of shared decision making with the woman that also considers the resources and policies of the delivery setting.
- American College of Obstetricians and Gynecologists,. ACOG Committee Opinion No 579: Definition of term pregnancy. Obstet Gynecol. 2013 Nov;122(5):1139-40. doi: 10.1097/01.AOG.0000437385.88715.4a.
- American College of Obstetricians and Gynecologists. Practice bulletin no. 146: Management of late-term and postterm pregnancies. Obstet Gynecol. 2014 Aug;124(2 Pt 1):390-6. doi: 10.1097/01.AOG.0000452744.06088.48.
- Grobman WA, Rice MM, Reddy UM et al. Labor Induction versus Expectant Management in Low-Risk Nulliparous Women. N Engl J Med. 2018 Aug 9;379(6):513-523. doi: 10.1056/NEJMoa1800566.
Initial Approval November 2018
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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.
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