What should I do if I go past my due date?

When will my baby come? Why won't my baby come? Can't you make may baby come? These are the questions obstetricians hear as women approach, reach, and then pass their due date.  There are no easy answer to such queries—and my patients rarely laugh when I tell them their kid must be watching a good movie inside and will come as soon its over—but in this blog, I'll try to sketch out some of the approaches to the common situation of going past your due date.

To start, the choices are probably obvious to all: either wait for labor to come or use medications to induce labor.  Waiting (so called "expectant management") has the appeal of doing something natural. And in uncomplicated pregnancies, being too impatient will just complicate what should be a quick and simple process. On the other hand, waiting too long carries the risk that when labor does come, the baby won't tolerate labor. The further one is past the due date, the more likely that non-reassuring patterns of the fetal heart rate or meconium stained fluid (a result of the baby moving its bowels while still inside, a reflex response to a stressful environment) will be present and, perhaps, lead to cesarean delivery. Very rarely, as doctors and patients wait, something horrible happens: stillbirth is what every doctor and patient fears, but is also a very unusual occurrence.

Induction means being in the hospital to start the process of labor and often means that labor will be longer than it would have been if you waited for it to come of its own accord.  My own experience and many studies suggest that inducing labor also carries an increased risk of eventually needing a cesarean delivery if, in spite of time, medications, and best efforts, labor fails to progress appropriately.  This should not be a surprise because, after all, with induction we're trying to force the body to do something it wasn't quite ready to do.  The risk of failed induction seems higher in women who have never had a previous vaginal delivery or who have a cervix that hasn't yet started to dilate (known as a "long and closed" cervix).

So how to choose between these two paths?  For my healthy patients with uncomplicated pregnancies I generally recommend waiting at least one week but no more than two weeks past the best estimated due date.  When exactly to plan induction in this interval depends in part on a patient's sensibilities: At this point, some women can't stand being pregnant a day longer and they don't fear induction, others are happy waiting and would prefer to have labor begin on its own. The cervical exam and everyone's schedules also come into play. One large study suggested that the rate of cesarean delivery is no different whether induction is planned at the beginning of the 42nd week (7 days past the due date) or the end of that week (the 43rd week, 14 days past the due date).  It seems that the extra cesareans needed due to un unsuccessfully induced pregnancies in the 42nd week are balanced by the cesareans needed by patients in the 43rd week whose babies are less tolerant of labor.

Sometime around when a pregnancy is a week past due, providers will often begin extra testing to help reassure themselves and their patients that all remains well with the pregnancy.  Such testing may include recording the fetal heart rate for a period of time ("non-stress testing") and an ultrasound to evaluate the fluid around the baby and the baby's movements ("evaluation of amniotic fluid volume" or a "biophysical profile"). If such testing raises concern, providers may recommend further testing or induction at that point.

For pregnancies in which problems have been identified in mother or baby, earlier delivery may be recommended. But for most healthy women with healthy pregnancies the best prescription as the due date approaches is also the one hardest to find in any pharmacy: patience.

Are you past your due date? What are you doing about it?

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Jeffrey Ecker, M.D., is an attending perinatologist (high-risk obstetrician) at Massachusetts General Hospital. He is also an Associate Professor at Harvard Medical School.

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