Induction of labour for improving birth outcomes for women at or beyond term
RHL practical aspects by Cuervo LG
FIRST CONTACT (PRIMARY CARE LEVEL)
In most cases post-term pregnancy does not lead to complications. However, the potential for serious complications, associated with the condition itself or with the traditional remedies used for it, need to be considered in choosing the setting where delivery care will be provided.
In developing countries, primary care settings are seldom equipped to deal with the risks and complications associated with post-term pregnancy and the effects of the folk remedies used to treat it. The safer option might be to refer women to the secondary level of care where both clinical and social support would be available [personal opinion].
Most women in developing countries do not have access to routine ultrasound in early pregnancy, which can help to reduce the diagnosis of post-term pregnancy. In the absence of routine ultrasound, a number of clinical methods can be used to estimate the gestational age of the fetus. However, for these methods to be effective it is important to educate women to attend antenatal clinic early in pregnancy. Careful enquiry into the menstrual history and clinical assessment of the uterine size at the first visit can be effective substitutes for ultrasound for the determination of gestational age. Many women in developing countries attend services other than antenatal clinics to confirm the pregnancy (e.g. family planning clinics, private doctors, pharmacies), but then delay attending antenatal clinics for months. Strategies may be developed to use these early visits to health care providers to determine the gestational age (1).
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
In uncomplicated pregnancies, it is recommended to induce labour after 41 completed weeks of gestation. Available evidence does not support the policy of induction of labour before 41 weeks in uncomplicated pregnancies. Every possible precaution should be taken to obtain a reliable estimate of gestational age prior to induction of labour. Failure to do so can increase the risk of such adverse consequences as iatrogenic respiratory distress syndrome. When there is uncertainty about the delivery date late in pregnancy, ultrasound can be used to evaluate the level of amniotic fluid for reassurance [personal opinion].
AT HOME OR IN THE COMMUNITY
The management of post-term delivery should take place at the secondary level of care, where facilities for induction of labour are available. Home care can involve monitoring of women with a post-term pregnancy, but this should be considered only where access to proper and timely referral and care is secured [personal opinion].
Families and communities should be informed and educated about:
- benefits of early antenatal clinic attendance
- risks of post-term pregnancy
- risks of traditional/folk remedies
- use of breast and nipple stimulation.
- Jeffery BS, Tsuari M, Pistorius LR, Makin J, Pattinson RC. The impact of a pregnancy confirmation clinic on the commencement of antenatal care. South African medical journal 2000;90:153-156.
This document should be cited as: Cuervo LG. Induction of labour for improving birth outcomes for women at or beyond term: RHL practical aspects (last revised: 28 December 2006). The WHO Reproductive Health Library; Geneva: World Health Organization.