Episode 3 - Due Dates
[0:00] Welcome to the Great Birth Rebellion podcast. I'm your host, Dr. Melanie Jackson. I'm a clinical and research midwife with my PhD, and each episode, I cast a critical eye over current maternity care practice by grappling with research and historical knowledge to help you get the best out of your pregnancy, birth, and postpartum journey.
[0:25] Welcome to today's episode of the Great Birth Rebellion podcast. I'm here to help you get the best out of your pregnancy, birth and postpartum journey. And today I'm talking about the options that you have if your pregnancy goes past your due date. So we'll start by talking about the ways that we estimate due dates, the problems with due date calculations, which will help you understand what it means to actually be past your due date. So then you'll hear the reality of what happens to you if you go past your due date and also what you might be told by your care provider about that. I'll touch on induction for due dates and why many practitioners will recommend an induction if you go past a certain part of your pregnancy. Some hospital policies will have it 10 days past 40 weeks, some are different, some are 41 weeks, it just depends on where you're giving birth.
[1:27] As a private midwife I personally don't routinely recommend induction for post-dates just so you know that. Coming into this episode my personal clinical practice is to go off the wellness of the woman and the baby to give as much information as possible so that she can make the decision that feels best for her but it's not my immediate default position to offer routine induction for women who are over 41 weeks and we'll talk about the intricacies of that.
[1:58] This episode won't be giving any guidance on natural induction methods. So if you've come here thinking, oh, I am overdue. What do I do? How do I get my baby out? This is not really a how to get your baby out episode. This is more of a how to keep your baby in till full term episode. So you might be offered an induction, as I said, if you are more than 10 days past 40 weeks but it's not always really necessary so stay tuned and we're going to talk about that, and you'll also love this episode if you've ever been given multiple different
[2:39] due dates or you've been told that you need to be induced for being overdue. I'm doing speech marks overdue when I say overdue. So let's get started.
[2:51] First let's talk about what a full and normal term pregnancy is. So a normal term pregnancy is considered between 37 weeks and 42 weeks. Obviously there are some outliers and women can have healthy babies that are born at 36 weeks or earlier or 43 weeks and I've even heard of women having their babies at 44 weeks. But on the whole a normal gestation is 37 to 42 weeks and that represents full term. But there's also some chatter in the research stating that we should be redefining these parameters to suggest that 39 weeks to 42 weeks is more likely a normal gestation because there's so much difference in brain development between a 37-weeker and a 39-weeker. So there has been a response of late from researchers to the growing number of women who are being induced at 37 weeks by their clinicians.
[3:53] So some clinicians who offer inductions a lot of inductions they might like that 37 weeks is considered full term because now they can induce women at 37 weeks because they're full term and this is not me just kind of taking cheap shots at clinicians who do lots of inductions statistically at least here in Australia the induction rate is going up and the biggest rise is not in the later term pregnancies the biggest rise is in the group of women who are between 37 and 38 weeks pregnant and there is a call to increase this kind of ready for birth date to 39 weeks to remind clinicians that when you get a baby out early you interrupt their full and complete development so the evidence shows that the closer to 40 weeks or full time you know 40 weeks and beyond.
[4:52] That you can have your baby, there's data on the long-term outcomes at least. I'm sure there are some short-term benefits to being full-term, of course. But even the long-term outcomes, then they look at school outcomes and IQ and cognitive development of babies that reach 40 weeks than those who didn't. And I hope women hearing this aren't thinking, oh my, my baby was born at 37 weeks, are they going to be okay? hey, I hear you. My baby, my first baby was born at 36 weeks. I just naturally went into labor at that time. So I'm hearing you. You know, we all think about our little early babes and what the long-term implications are of being early. And, you know, when we learn information that we can't really do anything about, we can't change the past, we can only learn more to impact our future.
[5:49] So give that four a little bit of space. Know that you can't change it for now. I mean, my babe's doing great. He's 12 now and I hope your early term babies are also thriving and there's more to life than school achievements if that's
[6:04] what we're going for. So that's my first point.
[6:07] A normal gestation is considered up to 42 weeks. So the question I'm going to ask and answer later, because it's my podcast, is why are you being offered an induction at 41 weeks or 41 weeks and three days why is that being offered we'll talk about that so firstly how is your estimated due date or your due date calculated and how accurate is it now go with me on this I think I feel like I'm going to harp on a little bit too long about how they do this but it's all purposeful I'm telling you this for a reason you need to know this so I can tell you the next thing so your estimated due date that you've got so the doctor or midwife or whoever you're seeing will say this is your due date and that due date is the 40th week of your pregnancy and only about five percent of women will actually have their babies on their estimated due date so I don't know why they didn't make the estimated due date to be the 42-week mark. They could definitely have, but they chose 40 weeks. So just remember your due date isn't your 42-week mark. It represents your 40-week mark. And then if you go over 40 weeks, they start to call you post-dates, which means you'll be on 40 weeks. You're not like overdue.
[7:30] You're just pregnant beyond 40 weeks. So post-dates doesn't mean overdue. You're just over your due date your baby isn't a muffin drying out in the oven the longer that you're pregnant that's not what's happening so all of this language is a little bit like it pathologizes the whole idea.
[7:50] So even though the wording gives off that feeling, you're not sort of a ticking time bomb. So I like to use the word post-term, which means that you're beyond the usual term of pregnancy. So beyond 42 weeks, basically.
[8:07] So post-term. So all of these words could be used to describe your pregnancy when you're over 40 weeks. I'm not saying it's right or accurate, but that's what you might hear.
[8:16] And also if you're looking at your clinical records so if you've got hold of any notes that your clinician's making the estimated due date is recorded with the acronym edd estimated due date or sometimes this can mean estimated date of delivery which delivery is not really a word we should be using babies are born not delivered or estimated date of birth edb and that's the acronym that I prefer estimated date of birth it feels like it most accurately represents what the date means it feels respectful and it just acknowledges that an estimated that it's an estimated date and it calls birth birth instead of delivery and this is one of my bugbears that the last way you might see it written somewhere is EDC estimated date of confinement and that is a relic of olden day maternity care where women were described as being confined to hospital for their birth and so their estimated date of confinement is the time where they'd get confined it's just horrible language so let's change that if we can midwives let's take that language back and change it up so if you get a chance and you see edc written anywhere estimated date of confinement.
[9:38] Go ahead and stage a silent protest and just change it to EDB and write EDB instead of EDC from now on. We don't confine women. They give birth around an estimated due date.
[9:53] And let me give you a top tip here, if you're listening and you haven't already told everyone your due date yet, is that when you start to approach your due date and your 40-week date, you'll get lots of well-meaning friends and family subtly or aggressively texting and calling and asking if you've had the baby yet or asking when your induction is booked for. Everybody is very invested in knowing if and when your baby is going to be born, apparently. But even more so, they're texting and calling to find out if you had the baby and you didn't tell them. So I've got a few practical tips here. First, you can tell them your due date is whatever date you'll be at 42 weeks. So give them a fake date if you don't want to be bothered. And so you basically would let them know that your due date is actually two weeks later than the one you've been given. and you can give them a vague date if you want to. So like I'm due at the end of April or the beginning of May. However you want to phrase it, you know, to avoid those text messages. Women hate getting those repeated messages from well-meaning people asking about when the baby's coming. When a woman is heavily pregnant and waiting for her baby, she does not want to be responding to multiple texts a day asking where the baby is. It's still inside me.
[11:20] But if you're listening and you're pregnant and you've already told everyone what your 40-week due day is and you do start to get messages asking about where the baby is, here's my suggestion.
[11:32] Is just start to create like a short series of photos that you can send people if they ask you if you've had the baby yet. Just like dress a watermelon in baby clothes and wrap it in a swaddle or something. Take a series of photos that you can store to use at the right moment so the baby watermelon might be sleeping in one photo you know dad having skin to skin with the watermelon, do a little nice little family photo shoot with the watermelon baby, and just when you're texting them a little caption mom and bub doing well we'll let you know when we're ready for visitors so that's just one little top tip people will very quickly get the message and I've gotten the ball rolling with coming up with that response to the where is the baby texts but do feel free to come up with some of your own and really make a good joke of it in your last weeks of pregnancy they'll be an absolute blast just you and your partner coming up with new messages to send so hopefully all those people will get the message but it bothers women so don't do it yourself and come up with some fancy ways to respond to those particular messages.
[12:49] So as I've subtly alluded to firstly we have to acknowledge that your calculated due date is always an estimate it's not accurate to the day in fact the best we can do particularly with ultrasound is to estimate within six days of your actual 40-week mark, your due date estimate.
[13:10] And let me talk you through how else we would work out your due date. So ultrasound's one way and we'll talk about that. But let's talk about this fella, Franz Nagel, who died in 1851. He was a German obstetrician and he came up with Nagel's rule.
[13:31] And that's where this whole due date saga began. So German obstetrician, you can imagine that maybe in the 1800s, Maybe he was in the middle of his life when he came up with this, what is still now called the Nagel's rule. So we're still using it. And it's a completely medical idea of pregnancy. Remembering it wasn't women who were defining and describing pregnancy back in the 1800s. It was men coming up with all the rules that would govern our bodies. To this day in 2025, the men and this particular man, Nagel, who defined and described what normal pregnancy, I'm doing normal in inverted commas, pregnancy length was back in the 1800s still controls and governs what is done to our bodies today because way back then they decided to put a number on our due dates.
[14:23] So the reason I'm telling you all this about our friend Nagel is because miscalculation of your due date is actually the most common cause of going overdue. That's a little known factoid. The most likely cause of you being classified as post-dates or overdue is not because your pregnancy has gone beyond 40 weeks or 41 weeks, but because somebody miscalculated your due date. So just like many things in maternity care, although you're given an exact date, it's only an estimation, but your care provider might use it as gospel. And many do, even down to the fact that inductions are booked based on the number of individual days that you're over your estimated due date. I've read policies that said women will be offered induction at 40 weeks and 10 days. But your due date is an estimate.
[15:16] And miscalculation is the top reason that you will be classified post-dates and possibly even offered an induction because of it. So NAGLE, NAGLE's rule relies on women knowing when the start of their last period was. So it's a bit of a maths game. And all of the apps and the little programs that you put your due date into, they're all based on NAGLE's rule. That's how they're programmed, all the online calculators.
[15:44] So Nagel's rule or Nagel's calculation it relies on women knowing the start of their last menstrual period then you add seven days and then subtract three months and add a year and it gives you your approximate due date as I said the the apps and calculators will do that and it's about, 10 months time so we're not pregnant for nine months lots of people think we're pregnant for nine months. It's actually 10 months and traditionally women would have counted 10 moons so that they knew where they were up to. The other issue with Nagel's rule is that it's based on women who have a 28-day bleeding cycle. So if your menstrual bleed comes earlier or later than 28 days or your cycle is irregular then Nagel's rule is less accurate. There's some little strategies you can use to adjust it. So because it's based on a regular 28 day bleed cycle, if your menstrual blood comes earlier than 28 days or say you have a 38 day cycle you have to add or minus days from Nagel's rule. So if you've added seven days because you have a 28 day cycle.
[17:00] But you bleed for 30 days then you have to add two more days so you would add nine days instead of seven and for example if you have a shorter cycle then you would only add five days instead of seven so you've adjusted it you don't have to know all this I'm just you know giving details.
[17:18] But we also use those little so I have a little wheel which tells you you know points the arrow to the date of last period and then it'll go all the way around and it's calculated off Nagel's rule and tell you when your estimated due date is and then I have to manually ask women and And hopefully your care provider has asked you how many bleeding days you have. And then I'll go ahead and add two days or three days or minus depending on the woman's cycle. So, but if I'm going to really blow your mind, because, you know, I know I have already with all of this super interesting information about NAGLE.
[17:54] Is that if you apply Nagel's rule to your pregnancy, it'll tell you that you're four or five weeks pregnant. By the time you skip your bleed, it'll say, yeah, you're five weeks pregnant or you're four weeks pregnant. But actually, you don't get pregnant to like the middle of your cycle. But Nagel counts it from the beginning of your cycle.
[18:17] Also Nagel's rule is based on if that women ovulate around day 14 but some women ovulate earlier and some women ovulate later than that and then also it assumes that you ovulate that you have sex that day and that the spermies have arrived at the egg that day so people are actually going to conceive at different times of their cycle actually based on ovulation based on how long it takes the sperm to get the egg get to the egg based on when they had sex so the rule is assuming that everyone has a 28 day cycle that everyone ovulates on day 14 that everyone had sex on that day and everyone conceives on that day and you're allowed to add or minus some days based on when you bleed but what happens if you ovulate on day 18 or 12 or 21 so if you've got an irregular cycle you don't really and you don't really know when you ovulated which is a lot of people a lot of women when your next you don't know when your next period is supposed to come Nagel's rule is inaccurate so what I'm saying a long way of saying is that Nagel's rule takes your pregnancy start date right back to your first day of bleeding and you actually haven't got pregnant for a couple of weeks already so that's just a little other interesting factoid.
[19:46] And I told you that to tell you this that for women who know exactly when they ovulated or exactly when they conceive so some women are tracking their cycle and they know exactly their ovulation date and they have sex on that day and then their hormones change and they can track that Or some women have been having assisted reproductive technology health, so IVF and things like that, and they can almost pinpoint the day of conception. Then you only add 38 weeks, and that brings you to your 40-week pregnancy date. Okay, that's all I'm going to say about Nagel's rule now. That's what everything is calculated off. and in clinical practice you can either do that manually on a calculator you know if you're part of the 1800s there's there's the wheel i still use a paper wheel and i add all minus days depending on the woman's cycle computer programs will do it automatically and certainly hospital booking calculations are automated.
[20:45] But even if you know your conception date or just your last period date accurately, then also modern maternity care systems don't always trust that women know things.
[20:56] So now the guidelines are recommending that every woman have a dating scan, so somewhere in between six and eight weeks. Even if you know your last period or your conception date pregnancy guidelines are recommending using the dating scan as the more authoritative way to calculate your estimated date of birth and if your dating scan is a week or more different to your estimated due date based on Nagel's rule in your last menstrual period then they trust the ultrasound more than your recollection of your body's functions but just know that although it's advertised as a more accurate way some research suggests that they can still be six days out six days different so then fast forward if you're 41 weeks and three days for example and your clinician has offered you an induction and then you start thinking about how accurate is my estimated due date in the calculation it might not be one or two days out it could be six days out and that those days actually become important at the end when you're negotiating your end of pregnancy.
[22:07] Care are you going to plan an induction based solely on an estimated due date that we know is based on Nagel's rule which we already heard in very thorough detail is not particularly accurate or an ultrasound that can be six days out.
[22:27] Now, because I said earlier, miscalculation is the most common cause of needing induction or being offered an induction for post dates. But there is a way you can triangulate your due date for maybe a more accurate estimation if you really want it, a really accurate estimation.
[22:47] So, if your estimated due date based on Nagel's rule is more than a week out from the estimated due date given to you by your dating scan, then they'll go by the dating scan. But if the estimated due date based on Nagel's rule and the ultrasound is pretty close within a day or two, then the accuracy of that is superior to the two estimates alone. And interestingly take this or leave it there is some research that seems to show that if you just base calculations off the last menstrual period so off Nagel's rule this typically plots pregnancies further along than the ultrasound and it can leave women prone to being classed as being overdue at the end of their pregnancy so when they compared it to ultrasound estimates not saying it's right or wrong just so you know and you have every right to decline that first dating scan of course if you're really certain then you don't necessarily need to have that dating scan although it can offer you other things so consider what else it might tell you even if you don't want to get information about the due date it can tell you if your baby has a heartbeat early on if there's more than one baby maybe there's two
[24:08] or three in there and it can give you a rough estimation of your due date.
[24:13] So that's a run through on how we estimate your due date and I went to a bit of detail but you can see that it's an inexact science and that it makes a massive difference to women when they're in hospitals or being cared for in a hospital system that's pushing inductions on women at a particular time and they're counting every single day for a woman's pregnancy as if the woman sort of somehow becomes some it's like some deviant act to be more than 41 weeks pregnant.
[24:46] Let's first have a look at some of the reasons why your pregnancy might be over 41 weeks. So the first reason is that it's completely normal and you're just pregnant. Your baby's still growing and developing and it's just taking the time that it needs to be fully developed. No problem, no pathology. Some babies are term at 37 weeks, some need to gestate to 43 weeks, some go to 42 and then they're ready. And it's just there's a complex web of things that have to happen in order for firstly your baby to finish their development and then to trigger off labor we don't really know what triggers off labor exactly what happens in yours and your baby's body that interact and trigger off labor the reason you are post dates is because the medical definition is not right and they've just labeled you as pathological and deviant when you aren't you're just having normal term pregnancy so that could be one reason.
[25:51] The main reason. The second reason why you might be post-dates is that you just always gestate long. That could be your genetic predisposition and I've certainly had clients who were very comfortable with long pregnancies. Their mums had long pregnancies, their sisters do the same and so do they. That's just normal for them. As I spoke about earlier the other reason was that somebody along the line has inaccurately estimated your due date and you're still just having a regular and normal pregnancy but because someone's inaccurately calculated your due date you're considered further along than you actually are there might be a pathological reason for why you haven't gone into labor sometimes there are there are things that are wrong with the baby and they just don't or can't trigger labor and more rarely there could be an issue with a woman's uterine tissue that prevents her from going into labor. I've only seen this twice, maybe three times in my whole career. In these circumstances, the woman just never goes into labor, doesn't respond to artificial oxytocin, and in the end needs to give birth by cesarean section.
[27:03] Now let's have a look at what might happen to you or what might be offered to you if your pregnancy does go over 41 weeks and the question I want to ask is why the rush because there's an awful lot of rushing to get the baby out simply for the reason of being post date so why is that so the recent mothers and babies report that was released in 2024 here in Australia showed that our induction rate for first-time mothers is 43% and it's 33% overall. So one third of all pregnancies here in Australia, and actually this is mimicked overseas as well.
[27:52] Are induced and 10% of those inductions are for post-dates pregnancy of which we just learned that the main cause is medical miscalculation of due dates not to mention that actually most of those inductions are offered before 42 weeks not beyond it so just a few somber stats for you there now you can have a really positive induction some women actually do need them I'm not suggesting we do away with them all together but it is scandalous that 43 percent of first-time mothers are being induced and that one in three women don't get to start labor on their own it's not right it's actually not improving outcomes and we can just stop that if anyone's listening just stop it. So I've done a lot of delving into the post dates and beyond 42 week research and initially the research was for my own clients because I'm still a clinical midwife and invariably there are few women a year who are pregnant beyond 42 weeks and it's my job to give them as much information as I can about their care options.
[29:07] That includes the risks and benefits of staying pregnant and going into labor without an induction and then also to inform them of their induction options and the risks and benefits of that choice. So it's not my job to recommend one option over the other. I'm going to say that again.
[29:25] It is not my job or your clinician's job to recommend one management plan over the other. It's my job to give my clients as much information I possibly can about their own well-being, about the research, about the risks and benefits of all of their options. Give them the full menu and then they make the choice that feels right and best for them. If my communication and information is well-rounded, unbiased, carefully investigated and accurate to that woman's scenario, and I deliver it in a way that acknowledges that this is the woman's choice, then I've done my job.
[30:08] Now, of course, sometimes they'll say, Mel, what do you think? And I can give some of my predictions, but all my opinions, but I can't predict what is going to be best for this woman. I can't predict the outcomes. of what the short or long-term ones all I can give is information so back to the question.
[30:30] Why the rush why are we inducing women when they're barely past 41 weeks and here let's talk about the ARRIVE trial among others and actually the big outcome from the ARRIVE trial according to the authors and your clinician might use this trial the ARRIVE trial to encourage you to get an induction at 39 weeks but the big outcome that the authors found is that if you induce everyone every woman at 39 weeks well or not they seem to believe that this is the golden point in pregnancy where you don't have the issues of prematurity, like if you induce a woman at 37 weeks, then there's some issues with potential prematurity. If you induce them at 39 weeks, you reduce the chances of the baby suffering from side effects of being premature. So 39 weeks is considered the golden point because at 37 weeks, what does start to go up, really from 32 weeks, but 37 weeks is the rate of stillbirth birth it starts to to go up in pregnancy and they'll always quote you your care provider if they want you to have an induction for post dates they'll let you know that the research.
[31:53] States that stillbirth rates double once you go over 40 through 41 weeks the stillbirth rate doubles.
[32:01] And they've recommended the 39 week induction because that's kind of the crossover where you've reduced risk of prematurity and the risk of stillbirth hasn't started to increase too much in their eyes. So 39 weeks is kind of the sweet spot.
[32:23] So yes, they are not wrong. The research does show that stillbirth rates do double each week you're pregnant beyond 39 weeks. But that's a misleading way of describing it. Because at 41 weeks, your risk of stillbirth is 6 in 10,000.
[32:44] So that means if you had 10,000 women all pregnant in between that 40 and 41st week, six of those babies in 10,000 will be lost to stillbirth and this is just a general stat and I know it's different in different ethnicities and locations I know it's different depending on women's risk levels but if we look at generalized across the research if you bunch everybody in six in 10,000 now by the time you get over 41 weeks and you're approaching 42 weeks it increases from six to ten in 10,000 and this is stillbirth so not during labor while you're pregnant where your baby suddenly dies and I'm so sorry if this has happened to you of course losing one baby is too much and I don't want to sound like I'm brushing off these statistics as being minor I know for the families who have suffered loss of their baby that these statistics are meaningless I'm I suppose I'm offering them up as a reference point to understand the statistical information so that women can understand their chances of their baby dying from stillbirth and factor in this to their decision making so my intention is certainly not to minimize the loss of a baby so it's just for perspective we're talking in the 10,000s we're not talking in the 100s.
[34:08] It's not like one in 100 babies are going to be stillborn for every week pregnant that you are.
[34:17] So if you had 10,000 women all pregnant in the 40th to 41st week, six of those babies would be lost to stillbirth. So beyond 41 weeks, it's 10 in 10,000. And the paper for these stats are in the resource folder. For those who are on the podcast mailing list, if you want to check my work on this, please do sign up to the mailing list, get the resources. The details are in the show notes below and the resources just get sent to you. So you can look at the papers that I got these stats from.
[34:47] So yeah, theoretically the risk of stillbirth approximately doubles and that's what your care provider might be frightened of and that's what they would tell you and that's why they're recommending an induction for you for post dates is that your risk of stillbirth, the risk of your baby being stillborn is increasing. They aren't wrong. The risk of stillbirth is increasing but the risk is relatively small but it's up to you to decide about how you want to interpret that risk. Your clinician, if they want you to have an induction, will tell you that your risk of stillbirth is doubling. A clinician who wants to give you information that you can use to make your own decisions will tell you that your risk just went up from 6 in 10,000 to 10.8 in 10,000. And that is information that you can use to decide if you feel like that's a small risk or if it feels like a high risk to you, a large risk. That decision is up to you.
[35:52] Basically, though, you would need to induce nearly 10,000 women to avoid a 10 in 10,000 statistic. And to me, in my risk interpretation, that doesn't seem like a fair swap in terms of the impact that induction can have on a woman's experience, the pressure that it puts on an already struggling maternity care system. And then when you factor in the long-term outcomes on women and babies being induced, and we're learning more about the long-term negative impacts of overall health due to induction, do we want to be unnecessarily inducing well women and babies? So the importance of spontaneous labour seems to be lost and there's this massive overreaction to the statistical risk of 10 in 10,000.
[36:42] So what do you do? you find yourself in a situation where you're being told that you need to be induced and that they want to book your induction well you could firstly ask is this injunction being offered to me because it's your hospital policy to induce women at this stage in their pregnancy or do you have actual concerns for my baby are myself or my baby currently in danger or are you doing this as a preventative measure or because this is what every woman gets offered, Of course, if there are actual health concerns for you or your baby, you have one choice to make about timing of birth. But if there's nothing wrong, do you want an induction?
[37:26] And if you do want one, that's easy. The hospital is happy to arrange that. That is the flow of the river. That's where they want you to go. But if you don't want one, that's where you're going to have to navigate your care plan a little bit more strategically and individually.
[37:43] So for context, I'll let you know what I do with my clients who choose to continue their pregnancy up to and beyond 42 weeks. And the first thing is is that I keep meeting with them regularly and I'm their it's continuity of care that I offer so I've seen them all through their pregnancy and I just start seeing them more often if they go over 42 weeks acknowledging that yes there is a slight increase in the risk of things occurring when you're outside of normal term pregnancy not denying that so that's why we check in more. I usually see them, it can be daily depending on their needs and we're doing wellness checks. So there's also a lot of technology that you can use if you want to find out how well your baby is. So ultrasounds are not a bad way of working out placental function and blood flow through the placenta. Is it still functioning as it should? Because that's the other thing that people can say is that, you know, once you've hit your due date or after 41 weeks, your placenta slowly stops working. And you can have a look at, I did a podcast episode on this, of course, and it's called The Myth of the Aging Placenta. So you can get a full story on that, a whole episode on that line of maybe your placenta is going to slowly stop functioning the further in pregnancy you get. There's a link in the show notes if you want to listen to that one after you finish this one.
[39:12] So first, I'll offer my clients an ultrasound to check placental function, the amniotic fluid volume, because that can correlate with how well the placenta is functioning. And also, there's something called a biophysical profile, which kind of checks the wellness of the baby. They give them a score. And so I'm less interested in the size of the baby at this point. The baby's going to keep growing, usually, unless there's a placental issue. But I'm more interested in how well the baby is. is the baby and the placenta still well and healthy in which case in my eyes and if the woman chooses there's no reason to induce this pregnancy everybody's well and then you just encourage the woman to stay vigilant with checking in with her own baby and her own body regarding movements and how she intuitively feels the baby is and I keep checking on the wellness of the woman but it includes not only the physical stuff so blood pressure and all those things we can measure. But I'm looking at social support. How's she feeling emotionally? Is she ready to have a baby? Is she happy to just keep going? And her spiritual wellness, it's not just about checking physically.
[40:21] So then if everything's well, why not continue? You know, I let every woman know of their increasing risk of stillbirth. I tell them all the raw data and keep explaining the stats that I mentioned before and let them know that, you know, certainly the risk of stillbirth continues to compound each additional week of pregnancy and I just keep checking in with the woman about how she feels about that. We can engage with our local hospital services if we need to and you know involve them in the care as needed and then we just wait for the baby. There's only been three circumstances in the last 16 years where the.
[41:03] Clients of mine have been over 42 weeks and in the routine checking that we do with ultrasound and things, something's come up that we felt like needed further surveillance, closer surveillance, and as it turns out, intervention. So while normally if everything's well, we do all those checks and I can find no reason to recommend an induction, then we just keep going with the pregnancy. But there was one scenario I had a client and she was planning a VBAC at home her first cesarean she didn't feel was necessary and she went all the way to 42 weeks and of course we did an ultrasound at 42 weeks and everything was fine and normal amniotic fluid was normal everything was fine we'd planned to go back for an ultrasound in two days so I saw her the next day And then the following day we went into the hospital for an ultrasound and they said, whoa, there is no fluid, no amniotic fluid at all. And in the two days prior, there was amniotic fluid.
[42:09] And so we had a chat about what this could mean. Is there a placental issue? Is there an issue with the baby? Because, you know, the baby wheeze out amniotic fluid. So why isn't that happening? So this woman decided this was enough information for her. We decided on an induction, but because she was planning a VBAC, she was planning a vaginal birth after cesarean and she had a scar on her uterus, we didn't really want to use syntocin on medication. So she opted to just have her waters broken. And for her, that worked. She went into labor and she labored and labored. There was a point in her pregnancy where she herself was.
[42:50] Decided that something was wrong she's like no something is wrong this is not right I want to have another cesarean section and she did have another cesarean section the baby was beautiful and healthy and she was actually really happy with the outcome that was one of them where that we intervened and it was because of the the low amniotic fluid or the no amniotic fluid and she made that choice to have her baby yeah of course I support her choice then I had another client in a similar scenario but she this was her first baby so again we did the first ultrasound it was all completely fine in the follow-up ultrasound beyond 42 weeks again very low amniotic fluid and she opted also for an induction for her she hadn't had a v-back she wasn't planning a v-back I should say. So she did have oxytocin to the full induction method.
[43:47] Can I say though that inductions are often a lot more successful for women who are already at the end of full term, for women whose uterus is ready to receive oxytocin, artificial or not. So inductions are a lot less likely to be successful early on where the woman's uterus is not ready to receive oxytocin enough to create good strong labor hers was it worked beautifully she had the induction and aside from the induction everything else was so beautiful and as I would normally assist a woman in labor and in fact I can remember the midwife at the hospital was so supportive she came in and helped with massage and acupressure and the woman didn't need extra pain relief her husband was there to help her with massage and we used the tens and she was upright. It was really beautiful. She had her baby all fine and normal. And the third woman that comes to mind that I vividly remember, we intervened with her post-age pregnancy.
[44:54] I was doing the regular 42-week checks, and I'd actually been seeing this woman quite frequently because she had another condition called thrombocytopenia, which is where her platelets were really low. She'd been induced for her previous babies because of it. So for midwives and other people listening out there who understand this, her platelets were 80. We were still planning a home birth. There's the whole story behind that.
[45:19] But when I was doing her 42 week check her blood pressure was way high and as we started to investigate it seemed as though she was preeclamptic and we went into hospital she stayed there for three days to try and get her blood pressure under control and keep an eye on the preeclampsia development and after three days without being able to control any of those elements it was decided that we would go for induction but not the induction that she'd experienced before so again like with the first woman who'd labored before we broke her waters as the only method and a few hours later she went into labor and had her baby very quickly.
[46:04] Uh so that was a great outcome uh she did not bleed even though her platelets were 80 she had a physiological third stage all well and healthy and the women just decided it was time based on the findings of the wellness checks so if a woman is well why intervene ask yourself why are we intervening in this well healthy pregnancy is it only to avoid that theoretical risk of the increase in stillbirth risk but if we're checking and consider if you're doing those extra checks are you then also reducing the chances of stillbirth because of the intensity of care that this woman is getting it's just something I wonder so this alternative path beyond 42 weeks is doable if you have your own clinician who's willing to engage that intensely so because I care for my own clients and I'm a private midwife if I decide I want to see them every day or if They need care every day. I fit that in. So if you've got somebody who can adapt to your needs like that, then this alternative pathway is possible, especially if you've had continuity of care and they've been with you the whole time. But just know that if you decide to decline the post-8 induction and you go through a hospital system.
[47:27] They will just keep asking you when you would you like to book your induction so each time you go in for any kind of antenatal care or checks or ultrasounds it's very likely that you'll present be presented with the the question of when would you like to book your induction and so it's okay to say look I am actually just here to check that everything is still well that me and my baby is still well and if we're still well we plan on going into labor without an induction and I'll reconsider this option if for any reason my baby becomes unwell of course I'd be willing to consider up other options that's just one way that you can navigate this I'm not saying it's the only way but just know that if you decline these post dates strategies that the hospital will offer you and that's usually an induction, that you'll have to keep renegotiating your intention of a spontaneous labour each time that you see a care provider.
[48:28] But I do think that additional maternity care is a way to keep women safe as they go beyond 42 weeks.
[48:38] Now, all these things I just said about induction at 41 weeks and the choices to make around that are all going to feel a little bit meaningless to a lot of people because there's this one study it's called the SWEPIS study obviously that's a shortened acronym but if you want to see the full study it's in the resource folder for anybody who's on the mailing list for this podcast all the details in the show notes you get full access to all the research papers that I use to create every single episode so I will put the SWEPIS paper in the resource folder it's full text it's open access anyone can read it and actually it's of all research papers seems to be one of the easier ones to read so I do believe you'll be able to read that even if you're not a sciencey medical person.
[49:24] So let's talk about the SWEPIS study because your clinician might refer to it as a reason to encourage you and endorse induction by 41 weeks. So SWEPIS study was in Sweden there was 14 hospitals involved that's a good thing five of these hospitals were in the stockholm region and this is important for this study because these particular five hospitals had a strategy around caring for women between 41 42 weeks acknowledging that yes your stillbirth rate goes up every week that you're pregnant that's we spoke about that in earlier in the podcast that's not what we're refuting there seems to be an increase in stillbirth every week that you're pregnant.
[50:09] The mitigation strategy for that is a lot of people would say, well, why don't we just shorten the length of pregnancy? Reduce the chance of stillbirth by shortening the length of pregnancy. Let's induce women at 41 weeks. Why not?
[50:22] The stock home venues had a different strategy. They said, okay, there seems to be an increased risk of stillbirth. How can we mitigate that risk?
[50:32] And they said, well, maybe we just give those women more care and more monitoring. Watch them a little bit more closely as a risk mitigation strategy. And what the SWEPIS study found is it seems as though, and you'll see there's lots of holes in this study, it seems as though that strategy works and I'll tell you why. So 14 hospitals, the researchers intended on enrolling 10,000 women into this study, 5,000 in each group, but they stopped the study early and they recruited about 1,380 women to a group where they would be induced at 41 weeks and 1,380 women who would go to 42 weeks and then be induced if they didn't go into labor earlier. So those were the two groups. One got induced at 41 weeks, the others at 42 weeks.
[51:31] And they wanted to know if they induced you at 41 weeks, will that reduce the number of stillbirths? Now, they stopped the study early because they'd recruited that number, 1,380 women. And already by that time, in the group that was being induced at 42 weeks, there was already five stillbirths in that group compared to none in the induction group. So the safety committee went, whoa, whoa, we've got to stop it. We've got a clear winner here.
[52:01] We need to publish, and they just published the paper without recruiting all 10,000 women. So this is, it was a much smaller study than what they were intending to do. And they made conclusions based on the study that they did that they stopped early. Now, one of those five stillbirths, the baby had a undiagnosed heart condition, heart defect, and the other four were unexplained stillbirths the newspapers run with the news that you know induction at 41 weeks saves babies the news they didn't run with after this particular study is that none of the five still births happened in the stockholm region so there was five stockholm venues so the other nine that's where all of the stillbirths occurred in in that part the unique thing about the stockholm venues is that they had a clear structure and a clear plan and they gave women who were in their 41st and 42nd week more care and more monitoring during that last week compared to the other venues that didn't they just did routine the same care.
[53:16] So we could potentially actually say, yes, maybe induction is a risk mitigation strategy for the risk of stillbirth in between the 41st and 42nd week. But an equally effective strategy is to just give women more care, more monitoring, more attention in that last week. And it seems to also be an effective risk mitigation strategy. Why are we not talking about that? that when they gave women actual maternity care between 41 and 42 weeks, no babies died either compared to when you induced them at 41 weeks. So while some clinicians will go, right, inductions for everyone at 41 weeks, some might say, well, more care for everyone, more attention for every woman between 41 and 42 weeks compared to between 40 and 41, because that just as effective as induction at reducing stillbirths.
[54:19] The other thing to mention here is that all five stillbirths were in women having their first babies. So if you're having subsequent babies, none of the SWEPIS study is relevant to you because it's not generalizable. It wasn't big enough to get the information they needed about a variety of different women. So that's a limitation of this trial too. It's only relevant to a small number of low-risk first-time mothers who didn't get extra maternity care in their 41st to 42nd week. So I'll leave that with you to decide what risk mitigation strategy you want to take based on this kind of information, this particular study. So just by digging a little bit deeper into the SWEPIS study, you can see that it's not an open and closed case for inducing everyone at 41 weeks. It does offer some other risk mitigation strategies, such as just more attention and maternity care and surveillance for these women. That's another option.
[55:22] So to summarize what we've done today, we talked about the pitfalls of calculating
[55:27] due dates and how it's not really an accurate due date.
[55:31] It's an estimated date of birth. however that's really significant at the other end of your pregnancy when you're looking at the 41 and 42 week dates and they're trying to book an induction for you just remember your estimated due date was only an estimate so if they're arguing between days it's not necessarily accurate we talked about the fact that there is an increased rate of stillbirth every single week that you're pregnant beyond 37 weeks there is an increased risk of stillbirth it does double but remember the stats were between your 40th and 41st week there's a 6 in 10,000 chance of stillbirth between your 41st and 42nd week there's a 10 10 to 11 in 10,000 risk of stillbirth it does double but that relative risk is still very very small but that's the reason the risk of stillbirth is the reason why your clinician might be recommending an induction for you but remember from the SWEPIS study yes induction at 41 weeks is one option to mitigate this risk but the other option is just honing in with more care and attention on those women who are in their 41st and 42nd week of pregnancy to help mitigate the risk of stillbirth in later pregnancy.
[56:59] You've got choices and certainly induction is one of them, but there are other
[57:05] options that you could pursue if induction is not something that you want. And that's all I'm going to say about that this time.
[57:12] That has been this week's episode of The Great Birth Rebellion of what to do if you go overdue. To get access to the resources for each podcast episode, join the mailing list at melaniethemidwife.com and to support the work of this podcast, wear The Rebellion in the form of clothing and other merch at thegreatbirthrebellion.com. Follow me, Mel, @Melaniethemidwife on socials and the show @TheGreatBirthRebellion. All the details are in the show notes.
This transcript was produced by ai technology and may contain errors.
©2025 Melanie The Midwife
