REVIEW
pregnancy defined as >42 weeks has merit, in that it represents a
Prolonged pregnancy
Nicholas Walker
Jia Hwa Gan
Abstract
Prolonged pregnancy is defined by duration greater than 294 days
from the last menstrual period, or equivalent gestational age calcu-
lated by ultrasonic fetal biometry. The latter is a more accurate method
for establishing the diagnosis. The specific causes of prolonged preg-
nancy are unknown, but identified risk factors are nulliparity, increased
maternal weight, and previous history of prolonged pregnancy. Pro-
longed pregnancy is associated with obstetrical and neonatal adverse
outcomes, and the risks appear to increase along a spectrum with the
degree of prolongation. Prolonged pregnancy may be avoided by in-
terventions to cause delivery prior to 294 days gestation, including
complementary therapies, labour induction, or caesarean section.
The risks of these interventions must be considered in the context of
the low absolute risks of prolonged pregnancy. There remains no clear
evidence of benefit in these strategies from well-designed prospective
studies. However, retrospective studies have shown reduced perinatal
problems when methods to avoid prolonged pregnancy have been uti-
lized. In addition to consideration of risks, decision-making in cases of
prolonged pregnancy must also take into account healthcare re-
sources and maternal wishes.
Keywords fetal surveillance; induction of labour; post-maturity
syndrome; post-term pregnancy; prolonged pregnancy
Definition
The frequently-used terms ‘post-term’, ‘post-dates’ and ‘pro-
longed’ pregnancy are not universally understood to have the
same meaning. The general concept underlying these terms is to
denote a pregnancy that has passed a point in time beyond which
is considered too long. In actual terms, this point is thought by
various authorities to range from 41 to 43 weeks (287e301 days).
As one example, the International Federation of Gynaecology
and Obstetrics (FIGO) defines it as more than 42 completed
weeks (294 days) from the last menstrual period. The original
idea that 42 weeks was a point of significance appears to have
originated in a Swedish study published in 1956, which
demonstrated sharp increases in perinatal mortality after this
length of gestation. In the modern and more practical context,
most studies examining interventions for managing prolonged
pregnancy use 41e42 weeks. >From an epidemiological
perspective, it is recognized that around five to ten percent of
pregnancies will be of 42 weeks’ duration. Thus, prolonged
Nicholas Walker MBChB FRANZCOG is a Consultant Obstetrician and
Gynaecologist at Auckland City Hospital, Auckland, New Zealand.
Conflicts of interest: none declared.
Jia Hwa Gan MBChB DipOMG is a Trainee Registrar in Obstetrics and
Gynaecology at Auckland City Hospital, Auckland, New Zealand.
Conflicts of interest: none declared.
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statistically outlying phenomenon (by the same logic that small
for gestational age fetuses are defined as those below the 10th
centile of the range of distribution).
Post-maturity syndrome, by contrast, describes a neonatal
clinical syndrome of features identified at delivery. Such features
include little or absent vernix and lanugo, wasting of intra-
abdominal fat, skin changes such as wrinkling or peeling, and
meconium staining of the cutis and nails. Post-maturity syn-
drome may rarely be seen in apparently term neonates, and has
been observed to occur in around 10% of gestations between 41
and 42 weeks, steadily increasing to around 33% at 43 weeks.
Incidence
Prolonged pregnancy has reported incidences ranging from 4 to
18%, depending on the definition used. A useful benchmark
figure is an incidence rate of 10%, which equally fits into the
notion that prolonged pregnancy represents, in most cases, a
statistical deviation of a range of gestation length. The incidence
of prolonged pregnancy appears to be reducing over time, which
is likely to be in part due to increased obstetric intervention rates
in healthcare systems where such data are collected. These
increased intervention rates are themselves due to increasing
rates of advanced maternal age among nulliparous women, with
the attendant increased risks of hypertensive disorders, diabetes
and fetal growth abnormalities. More widespread use of early
pregnancy ultrasound has also probably contributed to the
reducing rates of prolonged pregnancy.
Calculation of gestational age
In order to correctly diagnose prolonged pregnancy, it is critical
to have an established estimated due date (EDD). It is now well
established that first trimester ultrasound is the most accurate
method for determining gestational age and therefore the EDD.
Ultrasound is widely available in most developed countries and
the techniques to assess gestational age by either gestational sac
diameter, fetal crown rump length (CRL) or biparietal diameter
(BPD) are easily learned. Even when the date of the last men-
strual period is known, an ultrasound may demonstrate a
significantly different EDD because of inherent variations in the
follicular phase of the ovarian cycle, even in women with regular
menses. Another potential confounding factor is the occurrence
of first trimester bleeding, which may be mistaken for menstru-
ation, thus underestimating the EDD when pregnancy is subse-
quently diagnosed. Ultrasound is also the only reasonable way of
calculating the EDD of a pregnancy when the last menstrual
period is unsure or unknown. Since up to half of all pregnancies
may be unplanned and unexpected, ultrasound is an important
investigation for both the accurate diagnosis of prolonged preg-
nancy, and the avoidance of unnecessary interventions. This is
reflected in the National Institute of Clinical Excellence (NICE)
recommendations, which state that all pregnant patients should
be offered an ultrasound between 10 and 13 weeks’ gestation.
Risk factors
The most consistently observed risk factors for prolonged preg-
nancy include nulliparity, maternal body mass index (BMI) >25
311 Ó 2017 Published by Elsevier Ltd.
 REVIEW
kg/m2, male fetal gender, and previous history of prolonged
pregnancy. In relation to the final factor, it is noteworthy and
biologically interesting that if a woman experiences a prolonged
pregnancy with one partner, the recurrence rate is 20%, but in
the case of a new partner, the recurrence risk falls to 15%. The
same study also found that if the first birth is term, only 7.7% of
subsequent pregnancies were post-term. In addition, if the
woman’s first pregnancy was not prolonged, changing paternity
did not change the risk that subsequent pregnancy would be
prolonged also. This observation may indicate a paternally
derived genetic influence on gestational length that should be of
interest for further research.
Aetiology, pathophysiology, and clinical risks
A useful way of considering prolonged pregnancy is to question
why labour has not yet begun. Prolonged pregnancies are likely
to represent a final point arrived at by several different aetio-
logical mechanisms. The foremost to consider is that the preg-
nancy may be falsely prolonged due to an error of miscalculation
of the EDD, due to an absence of an ultrasound scan or perhaps a
human error in calculation. In the case of a certain EDD, it is
thought likely by many experts that prolonged pregnancy simply
represents an expected statistical phenomenon inherent in the
variability exhibited by biological systems in general. Potential
examples of such biologic variability could include any number
of unknown or known processes that are involved in the onset
and establishment of spontaneous labour. The number and
sensitivity of myometrial oxytocin receptors is known to increase
during the final stages of pregnancy, and these may differ in
prolonged pregnancy. Cervical prostaglandin production may be
delayed also in prolonged pregnancy. The development of
intermyometrial neurochemical and physical connections,
necessary for efficient uterine contractility, is known to be rela-
tively immature in nulliparous women when compared to parous
women, which may in part explain the increased risk of pro-
longed pregnancy observed in nulliparae.
More specifically, a failure of labour initiation may due to
known pathological states affecting the maternal fetal unit. X-
linked icthyosis is a condition characterized by deficiency in
placental steroid sulfatase enzymes, which has the effect of
causing abnormally low levels of oestrogen in affected male fe-
tuses. As the onset of labour is initiated in part by the fetus, this
steroid hormone imbalance can cause pregnancy prolongation.
Major abnormalities of the fetal central nervous or endocrine
systems, such as anencephaly and adrenal hypoplasia, are also
associated with prolonged pregnancy, probably by a similar but
as yet unknown underlying mechanism. It is suspected that more
minor, undefined fetal genetic variations may also influence the
onset of labour, though these have also not yet been elucidated.
Related to this is the observation that in the setting of prolonged
or post-term pregnancy, male fetal gender confers a higher risk of
unsuccessful labour induction.
Prolonged pregnancy is also noted to be associated with
cephalopelvic disproportion. It may be that this association is
causative, since if the fetal head does not engage and enter the
maternal pelvis, there is reduced physical pressure and disten-
tion of the lower uterine segment and cervix, with a resultant
reduction in cervical dilation, prostaglandin formation, and other
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numerous and incompletely understood chemical and mechani-
cal changes necessary for the initiation of labour. Evidence
supporting this theory may be inferred from the fact that suc-
cessful labour induction in post-term pregnancies is strongly
linked with the cervical Bishops score, a composite measure of
cervical characteristics and the relationship of the fetal head to
the maternal pelvis.
Risks associated with prolonged pregnancy can be divided
into complications for the mother and baby. The fetal compli-
cations are well described, but the pathophysiological mecha-
nisms underlying them remain obscure. Consistent increases in
risk are seen for the following conditions, along a spectrum that
increases as the gestational age increases:
 Macrosomia with traumatic injury
 Stillbirth
 Intrapartum asphyxia with sequelae
 Meconium aspiration
 Neonatal death
Macrosomia occurs when fetal growth continues unchecked by
the normal timing of labour and delivery. Stillbirth may be due to
placental insufficiency or dysfunction, with resultant impaired gas
exchange to the fetus. Stillbirth may also simply be a matter of
statistical probability, as a prolonged pregnancy allows a longer
timeframe for the events leading to stillbirth to occur. Both
placental insufficiency and macrosomia are linked to intrapartum
asphyxia, with the common sequelae being meconium aspiration,
hypoxic neonatal encephalopathy, neonatal seizures, and in the
most severe forms of the aforementioned, neonatal death.
The maternal complications of prolonged pregnancy are
linked closely with the fetal risks:
 Labour dystocia
 Genital tract trauma
 Caesarean section
 Post-partum haemorrhage
 Anxiety
The first two points follow from fetuses who are either mac-
rosomic or have failed to properly negotiate the maternal pelvis,
or both. The risk of caesarean section is increased due to these
reasons, in addition to the possible co-existent fetal problems
outlined above.
Management
In the management of a prolonged pregnancy, the first and
foremost step is to ensure the correct diagnosis by establishing
and double-checking the EDD, and the method by which it was
derived. The established margins of error for any ultrasound
scans should be used to interpret the supposed EDD, that is: 7
days for scans prior to 20 weeks’ gestation; 14 days for scans
between 20 and 30 weeks; 21 days for scans >30 weeks.
If prolonged pregnancy is confirmed, the next step is to rule
out any obstetric complications that would indicate planned de-
livery. Examples of this situation can be divided along the lines
of maternal conditions and fetal conditions. Such maternal con-
ditions would commonly include hypertensive disorders and
diabetes. Fetal indications for delivery include prelabour
amniorrhexis, and suspected fetal compromise. This may be
evidenced by oligohydramnios, reduced fetal movements,
growth restriction or abnormal fetal cardiotocography.
312 Ó 2017 Published by Elsevier Ltd.
 REVIEW
In addition, the wishes of the patient and her family should be
taken into account. There are two options to present to the pa-
tient: planned delivery or expectant management. In modern
healthcare, the ethical principles of patient autonomy, benefi-
cence, non-malifecence and justice may be used to guide profes-
sional conduct when managing prolonged pregnancy. To address
these principles individually, firstly one considers patient auton-
omy. Patients must have the right to accept or decline manage-
ment options for themselves, and, in the case of pregnancy, their
unborn children. They must be allowed sufficient time and sup-
port to consider these options and they must be given informa-
tion, including beneficial or detrimental evidence for such
options, in a form and manner which they are able to understand.
Patient autonomy is so important that even when a patient’s de-
cision conflicts strongly with best available evidence they must be
allowed to make that choice for themselves. In the case of pro-
longed pregnancy, the risks of expectant management are not
high, equating for example to an increased risk of stillbirth of
approximately 3e5 per 1000 (0.3e0.5%). Secondly, the ethical
principle of beneficence and its related negative form of non-
maleficence imply that medical staff should provide manage-
ment options that both improve outcomes and cause no harm. In
the case of planned delivery to avoid prolonged pregnancy, there
is certainly improved neonatal outcomes: the risk of stillbirth is
avoided. Furthermore, there is no significant increase in maternal
morbidity, as most studies do not demonstrate an increase in the
risk of caesarean section with planned delivery. Finally,
addressing the ethical principle of justice, management options
must take into account the ‘bigger picture’ with respect to fair
allocation of health resources. Prolonged pregnancies make up a
small burden (10%) of obstetric problems. The methods to
manage prolonged pregnancy are already incorporated into
routine obstetric practice, i.e. planned delivery (by labour in-
duction or caesarean section) and maternal and fetal surveillance.
Utilizing either option must account for the opportunity costs
incurred through such action. In resource-limited settings, pro-
longed pregnancy - with its low overall risks - may feature as a
lower priority compared to other higher risk obstetrical problems.
Planned delivery
If the woman and her family accept planned delivery as the
means to manage prolonged pregnancy, the next step is to decide
on the mode of delivery.
Induction of labour tends to be the default option offered in
many obstetric units, the details of which are described by an
institutional protocol that may involve admission to hospital,
cervical preparation with mechanical or pharmacological agents,
then amniotomy and oxytocin infusion as required. Cervical
preparation aims to improve the success of labour induction, and
where cervical preparation is inadequate, the odds of failed la-
bour induction are increased. Women should be advised that
cervical preparation may take 24e72 hours, which further pro-
longs the pregnancy. Amniotomy is useful for noting the pres-
ence or absence of meconium staining, but is known to increase
the risk of intrapartum umbilical cord compression and resultant
fetal heart rate abnormalities on CTG.
Patients should also be given the opportunity to discuss
caesarean section as a planned mode of delivery. The risks and
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benefits of this approach are too long to detail in this essay, but
key clinical information which may favour a planned caesarean
delivery include a history of previous caesarean delivery, breech
presentation, fetal macrosomia, unfavourable cervix, and pro-
jected future childbearing plans. An example of a case where
caesarean section might be the preferred mode of delivery offered
could be a 42 year old patient with a macrosomic fetus, an
unfavourable cervix, and with no plans for future childbearing
beyond the index pregnancy. Each case should be carefully
considered, and medical staff should aim to individualize care to
suit the patient, her family, and the obstetric unit.
Expectant management
Women who accept or wish to undergo expectant management
should be supported in their decision. They should be advised
that there is no evidence for fetal surveillance as a safeguard
against adverse outcome. If the patient wishes to undergo
spontaneous onset of labour rather than formal induction of la-
bour, an offer should be made to perform membrane sweeping.
This is a digital cervico-vaginal examination that disrupts the
interface between the fetal membranes and the lower uterine
segment, helping to initiate the biological cascade that leads to
labour. It is the only proven non-pharmacological method of
reducing the risk of prolonged pregnancy, and reducing the risk
that formal labour induction will be required.
If the patient wishes to undergo expectant management, the
option of the following surveillance strategies can be proffered,
however, the lack of certain benefit behind each must also be
explained to aid her decision-making.
Amniotic fluid volume
Oligohydramnios is usually viewed as a surrogate marker for
reduced placental efficiency, though the true mechanisms of
amniotic fluid regulation remain poorly understood. With
diminishing placental function, there is selective perfusion of the
brain and heart at the expense of other organs, including the
kidneys. As fetal urine production contributes significantly to
amount of amniotic fluid, a reduction in blood flow to the kid-
neys will decrease urine production and therefore overall amni-
otic fluid volume. Oligohydramnios complicates pregnancy by
increasing the risk and severity of umbilical cord compression in
labour and increasing the viscosity and concentrations of any
meconium that is present within the amniotic fluid.
There is still controversy around the definition for oligohy-
dramnios. Some definitions arbitrarily use an amniotic fluid
index (AFI) of <5 cm. Others define it as less than the fifth
percentile for the gestational age. The AFI is derived from the
sum total of four measured pockets amniotic fluid measured in
each uterine quadrant with the ultrasound probe perpendicular
to the abdominal wall. An alternative measurement is the
‘Maximal vertical pocket depth’ (MVPD), which is a single value
assigned to the deepest pocket of fluid seen on ultrasound scan.
An appropriate cut-off for a normal MVPD may be 2.7 cm, which
has a sensitivity of 50% and specificity of 89.7%. The only
randomized trial comparing the use of MVPD and AFI did not
show a difference in perinatal outcomes, but did show an in-
crease in obstetric intervention rates in those patients in whom
AFI was used.
313 Ó 2017 Published by Elsevier Ltd.
 REVIEW
Biophysical profile
The biophysical profile (BPP) is a composite score based on an
ultrasound assessment of the fetus and a non-stress test (car-
diotocograph or CTG). The ultrasound component consists of
evaluation of fetal tone, movements, breathing and quantifi-
cation of amniotic fluid. Each variable is scored 0 or 2 with no
intermediate score of 1. The four ultrasound variables allow for
a maximum score of 8, and when combined with the CTG
contribute to a maximum test result of 10. A maximum score of
8 (without CTG) or 10 (with CTG) is thought to indicate that
the fetus is in good condition. If the score is 6, the test should
be repeated in 4e6 hours, with a new score given. A score of 4
or less is an indication for planned delivery. The false-normal
test rate has been measured at 1:1000, and is defined as
the stillbirth of a structurally normal fetus following a normal
BPP.
Doppler ultrasound of fetal and uteroplacental
circulation
Despite extensive investigation on the role of Doppler studies in
prolonged pregnancy, there is no regimen of tests that consis-
tently identifies which fetuses are most at risk from complica-
tions. Umbilical artery Doppler velocimetry has not proved able
to improve the positive predictive value of fetal testing in pro-
longed pregnancy. Doppler studies of the fetal circulation looking
for changes that may be associated with adverse fetal outcomes
are inconsistent and are unable to predict adverse fetal outcomes
such as:
 Neonatal encephalopathy
 Urgent operative delivery
 Abnormal fetal heart rate change
 Thick meconium or acidaemia at delivery
Finally, more recent studies have been conducted using
Doppler measurements of umbilical and fetal cerebral blood flow
to assess for evidence of fetal redistribution of circulation to the
brain, thought to be a possible marker for fetal adaptive changes
to uteroplacental insufficiency. This index is known as the
cerebro-placental ratio (CPR). Measurement of the CPR in the
setting of prolonged pregnancy has not yet been found to identify
the fetus who will be at risk if they remain in-utero.
Timing of testing
There is no clear evidence or consensus as to when fetal testing
should begin. Identifying the most appropriate time to begin
testing will depend on weighing up the risk of an adverse
outcome versus the risk and cost of the intervention.
Traditionally, fetal monitoring is commenced at 42 weeks’
gestation due to the increase in morbidity and mortality after 42
weeks. It has been suggested that fetal testing could occur prior
to 42 weeks. This suggestion is based on the fact decreasing
uteroplacental function is a continuum over a period of time,
rather than any biologic cut-off that occurs at 42 weeks. Indeed,
large studies indicate that the nadir of poor perinatal outcomes
occurs around 41 weeks’ gestation, with steady increases beyond
that gestation.
The literature is inconsistent regarding the types of tests that
should be used to monitor the fetus during the postdate period. A
number of tests have been employed over the years including:
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 Fetal kick count chart
 Non stress test (cardiotocograph)
 Contraction stress test
 Ultrasound estimation of amniotic fluid
 Biophysical profile
Economic considerations
A state transition model has been used to estimate the cost-
effectiveness of four strategies of induction of labour (expectant
management vs induction at three differing postdates gestations).
The analysis showed that all three interventions were more
effective but more costly than expectant management. However,
as the interventions reduce the risks of prolonged pregnancy,
they are in fact more cost-effective than expectant management,
overall. The interpretation of these findings are similar to cost-
benefit analyses in other studies of labour induction for
different obstetrical indications, and suggest that the costs of
labour induction and intrapartum care are relatively fixed for
each patient. It is the accrued cost of delay e which relates to
increased clinical assessments e that is probably the main
contributor to the cost difference between the groups.
Intrapartum management
Intrapartum management should include electronic fetal moni-
toring (EFM) of women who have prolonged pregnancy. This
recommendation is based on the fact that EFM is a sensitive
predictor of intrapartum fetal hypoxia and acidosis, for which
fetuses of prolonged pregnancies are known to be at increased
risk.
Conclusion
Prolonged pregnancy represents a relatively small proportion of
modern obstetric practice. It is important to tailor management of
prolonged pregnancy according to the individual circumstances
at hand. Routine maternal and fetal assessment forms the basis of
clinical decision making, which involves either planned delivery
or expectant management. Due to the low absolute risks with
either approach, it is important to make decisions that take into
account the preferences and expectations of the woman and her
family where possible. A
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ences of being induced for post-date pregnancy. Women & Birth: J
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Greve T, Lundbye-Christensen S, Nickelsen CN, Secher NJ. Maternal
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