In their own sweet time: a journey into post-date pregnancy

 
In their own sweet time: a journey into post-date pregnancy
By Caroline (Cas) McCullough © 2007

This is an updated version of an article originally published in Natural Parenting Magazine in March, 2005.
 
Cas McCullough explores what it is like to have a long pregnancy and how to make informed decisions about interventions in a world where nearly every baby is born ‘on time’.
 
My first baby, Liam, was born at 38.5 weeks gestation by emergency caesarean section so, I didn’t have any idea how long I’d be pregnant for when I became pregnant with baby number two.
 
At 36 weeks I thought “any day now”. I just had a feeling that my baby was going to arrive early and I couldn’t wait. Thirty-eight weeks came and went and my baby had turned breech.
 
By 39 weeks he had decided to turn around and dropped into my pelvis. My belly was so low I could practically bounce it on the pavement. By 40 weeks I was about the size of the Titanic. Well meaning old ladies would stop me in the shopping centre and say, “you’re taking quite a risk being out now”. You should have seen their faces when I told them I was due any moment.
 
At 41 weeks I was starting to get nervous as none of the induction “tricks” I had tried were working. I had taken Evening Primrose Oil, had acupuncture, sex and went for long walks, all to no avail. When was this kid going to come out?
 
My doctor eyed me over and said, “Well, I’ll see you in the labour ward this weekend then.” But the weekend came and went and still nothing. I was getting desperate. I knew that if I got to 42 weeks and there was no sign of a baby, I was going to be under enormous pressure. Sure enough, at 42 weeks I found myself sitting in my doctor’s office still pregnant!
 
He said, “I think it’s time for you to have this baby.”
 
I really wanted my baby to be born naturally if possible as my previous caesarean had been very traumatic and I knew from the research I had read that induction may be an unwise option given I’d had a caesarean already (as induction increases the risks of uterine rupture) (1).
 
As such it was important to me to ensure that a planned caesarean was really warranted in this situation. So we went to see a Sonographer (a specialist radiologist who does ultrasounds) to check the baby’s wellbeing and were informed that due to the lack of fluid surrounding the baby, intervention would be prudent.
 
The next morning, at nearly 43 weeks gestation, Daniel was born by elective caesarean section.
 
In hindsight, I felt I made informed decisions about Daniel’s birth but I also felt I made informed decisions about my last baby’s birth. Adam, was born at 43.5 weeks with no complications whatsoever. Given the differences between each baby’s birth and the rarity of significant complications, I have often wondered at the wisdom of routine induction.
 
Fifty years ago a gestation period of 10 months wouldn’t have been a predicament. At that time, most women weren’t aware of when they’d conceived and nor could they tell from test results. So, if a woman went past the 41st week everyone was none the wiser - no one panicked! The wards weren’t full of women on Tuesdays and Thursdays for scheduled inductions and babies came in their own sweet time.
 
Nowadays it is a different story. Very few women continue with a pregnancy beyond 41 weeks and most are routinely scheduled for inductions should they reach that point. Some doctors will leave it until 42 weeks and even some until 43 or 44 weeks, but they are rarities (as are the number of women who reach that gestational age). Regardless of an obstetrician’s viewpoint on what constitutes post-dates, the one thing they seem to have in common is the idea that all pregnancies have a use-by-date.  One reason for this is that a study was done in Canada which showed the risks of unexplained still-birth were increased to 1 in 500 after 42 completed weeks gestation and doubled at 43 completed weeks gestation. Therefore for every baby that may die after the 42nd week, 499 are routinely subjected to intervention which can carry its own set of risks and problems (2,3).
 
So, once a woman reaches the magic 40 week mark she can suddenly feel pressure to perform. This pressure does not only come from doctors. It comes from partners, families, work colleagues, friends, acquaintances, neighbours and little old ladies in shopping centres. However, nobody has yet researched how the pressure put on women to birth their babies to a strict time schedule could potentially prolong pregnancies. Some have theorised that when the clock is ticking it can create enormous anxiety which can increase adrenalin levels (which can inhibit the onset or progress of labour) (4).
 
So what is this pressure cooker like? Second Pregnancy: All of sudden, the phone won’t stop ringing. “Have you had that baby yet?” asks my well-meaning 90-year-old great aunty. “Yes, I had it and didn’t tell anyone!”… well that’s what I wanted to say. “No, I’m still here!” I would say with a smile on my face and my fist clenched. Later the phone would be found in the rubbish bin.
 
Eventually we recorded a message informing callers the baby had not arrived and we would tell everyone when it did. Then when that didn’t stop callers we took the phone off the hook and stopped checking the email. In fact, me, an email addict - couldn’t even look at the computer. “Why won’t they just leave me alone?”
 
Beyond the social pressure there is also an internal struggle to deal with. There is such little information available on post-date pregnancies that it is very difficult to make an informed decision about the well-being of your baby based on medical research alone. I had researched my options thoroughly during my second pregnancy but was unprepared for the anxiety that came along in those final weeks. As much as I tried not to take others’ doubts on board, I constantly questioned myself and worried about my baby.
 
Every morning I woke up without a baby in my arms I would feel so disappointed. Then I started to get what I thought were contractions and thought “this is it” but alas, by the time I flopped into bed they would disappear. It was extremely frustrating and I was an emotional basket case by the time I reached 42 weeks. This was despite knowing that my baby was fine and that it was okay to have a baby past 42 weeks if the baby and I were well.
 
At that stage I felt very alone. Friends told me later they thought I had lost the plot and my husband thought I was being hormonal and emotional and even accused me of wanting to put my birth experience before my baby’s well-being. I just wanted to crawl into a great big hole. It felt like everyone around me had abandoned me in my hour of need. No wonder I felt sadly relieved when we made the decision to have the caesarean. I felt battered and bruised and just wanted it to be over.
 
3rd Pregnancy: I made some very different choices. I chose share-care between a midwife I knew and trusted and a consultant obstetrician. I chose to decline the 18 week scan and not have any scans for the remainder of my pregnancy because I felt a need to connect with my baby more intuitively rather than judge him or her based on size, weight, expected due date and any potential “defects” that might present during an ultrasound. I chose not to tell most people when my baby was due and “locked down” for the final few weeks. I did not check the email, I did not answer the phone and just tried to relax and spend time with my family. I accepted that “what will be, will be”.  I made a real effort to communicate openly with my husband, inform him as I became informed in a way that suited him, and involve him in the decision-making process.
 
Whatever choices a woman makes it is vital she feels supported and safe. It is important to be fully informed prior to making a decision regarding a post-date pregnancy and to also trust her intuition. Caregivers that are willing to respect and support women during this time can also make an enormous difference and take the “lid off” that pressure cooker environment.
 
Towards the end of my last pregnancy we monitored my baby’s movements carefully and had electronic foetal monitoring traces done every few days to see how he was doing. At no point was the obstetrician, the midwife or I worried that Adam wasn’t doing well. If we had been, I would have had another caesarean in a heart beat. At 43 weeks I asked my midwife to do a membrane sweep (which has been proven to help speed up the onset of labour) (5) and went and had some acupuncture. Those were the only interventions I had. After a long early labour and a very short active labour, Adam was born peacefully and naturally with no complications and a very healthy placenta.
 
Whether you choose to continue with a pregnancy until you go into spontaneous labour, have an elective caesarean or opt for induction of labour, examine your individual needs and the benefits, risks and alternatives so you can make an informed decision that is right for you and your family.
 
While I chose paths that might seem outside-the-box to some people, they were definitely the right paths for me and my babies. I feel confident that I weighed up all the options and the results were two empowering births with two healthy babies and a happy me.
 
What you can do to ease the pressure if you go past 40 weeks: 

• Consider being cared for by a known and trusted midwife for pregnancy and birth. If a medical problem becomes apparent your midwife will refer you to a specialist. Some hospitals run midwifery group practices or offer share care between obstetricians and midwives. Do your homework and find out which birth environment will best meet your needs.
• Accept that some babies take longer to “cook” than others and that it is normal to have a 42 week pregnancy or longer, especially if your menstrual cycle varies.
• Consider visiting a qualified homeopath or acupuncturist, try having sex, having your care provider do a membrane sweep, taking Evening Primrose Oil, taking castor oil with Apricot Nectar as options to move things along if you think you need to. Above all, make sure you’re aware of the risks and benefits of each alternative including doing nothing at all.
• Take the phone off the hook, or get people to phone or SMS your partner so that you are unaware of unwanted inquiries.
• Get your partner to check the email.
• If you agree to a sonogram or CTG (external continuous foetal monitoring) to check your baby’s well-being, get a second opinion from a qualified specialist before making a decision if there are any doubts about the baby’s wellbeing.  A second opinion rules out a false positive result.
• Don’t be hard on yourself for the decisions you make. All you can do is educate yourself as much as possible on your options and make an informed decision. No decision can be made lightly when it comes to the well-being of our babies and ourselves.
• Make sure that if you do agree to intervention, you negotiate with your care providers to ensure your emotional and physical needs are met.
• Make sure you fully understand what is involved with any proposed intervention (eg. vaginal examinations, breaking of your waters and use of Syntocinon to speed up labour if being induced) and how that might affect you emotionally and physically.
• Having a birth plan can make a huge difference to your sense of well-being because it enables you to clearly communicate to your care providers what is important to you.
• Above all, listen to your body, to your baby and to your heart. Get to know your baby’s sleep patterns and if your baby is moving a lot and your heart rates are fine take that as a good sign, relax and wait for baby to arrive.

(1) Kayani, S., and Alfirevic, Z. (2006). Induction of labour with previous caesarean delivery: where do we stand? Current Opinion in Obstetrics and Gynecology, 18:636–641.
(2) Hannah ME, Hannah WJ, Hellman J, Hewson S, Milner R, Willan A. Canadian Multicenter Post-Term Pregnancy Trial Group. Induction of Labour as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. N Engl J Med 1992;326:1587-1592.
(3) Crowley P. Interventions for preventing or improving the outcome of delivery at or beyond term (Cochrane Review). In: The Cochrane Library, Issue 2, 2004. Chichester, UK: John Wiley & Sons, Ltd.
(4) Buckley, S. (2005). Gentle birth, gentle mothering. One Moon Press. Melbourne.
(5) de Miranda, E., van der Bom, J., Bonsel, G., Bleker, O., Rosendaal. F. (2006). Membrane sweeping and prevention of post-term pregnancy in low-risk pregnancies: a randomised controlled trial. British Journal of Obstetrics and Gynaecology, 113:402–408