• American College of Obstetricians and Gynecologists (ACOG). Management of postterm pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Sep. 8 p. (ACOG practice bulletin; no. 55). [69 references]

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of postterm pregnancy. Washington (DC): American College of Obstetricians and Gynecologists; 1997 Oct. 6 p. (ACOG practice patterns; no. 6).

Postterm pregnancy

Management

Obstetrics and Gynecology

Physicians

• To aid practitioners in making decisions about appropriate obstetric and gynecologic care
• To examine the evidence and provide recommendations about two management strategies for postterm pregnancy: antenatal surveillance and induction of labor

Pregnant women who have completed 42 weeks of gestation or are 14 days beyond the estimated delivery date

1. Accurate assessment of gestational age (ultrasonographic validation)
2. Antenatal surveillance (nonstress testing, assessment of amniotic fluid volume estimation)
3. Assessment of cervical condition prior to labor induction
4. Induction of labor, including use of prostaglandin gels (dinoprostone or misoprostol)
5. Expectant management

• Maternal and perinatal morbidity and mortality
• Duration of labor (induction-to-delivery interval)
• Cesarean delivery rate among patients managed

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

The MEDLINE database, the Cochrane Library, and American College of Obstetricians and Gynecologists' own internal resources and documents were used to conduct a literature search to locate relevant articles published between January 1985 and April 2004. The search was restricted to articles published in the English language. Priority was given to articles reporting results of original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Guidelines published by organizations or institutions such as the National Institutes of Health and the American College of Obstetricians and Gynecologists were reviewed, and additional studies were located by reviewing bibliographies of identified articles.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force:

I: Evidence obtained from at least one properly designed randomized controlled trial

II-1: Evidence obtained from well-designed controlled trials without randomization

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Analysis of available evidence was given priority in formulating recommendations. When reliable research was not available, expert opinions from obstetrician–gynecologists were used. See also the "Rating Scheme for the Strength of Recommendations" field regarding Grade C recommendations.

Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

A formal cost analysis was not performed and published cost analyses were not reviewed.

Internal Peer Review

Practice Bulletins are validated by two internal clinical review panels composed of practicing obstetrician-gynecologists generalists and sub-specialists. The final guidelines are also reviewed and approved by the American College of Obstetricians and Gynecologists (ACOG) Executive Board.

The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of the "Major Recommendations" field.

The following recommendations are based on good and consistent scientific evidence (Level A):

• Women with postterm gestations who have unfavorable cervices can either undergo labor induction or be managed expectantly.
• Prostaglandin can be used in postterm pregnancies to promote cervical ripening and induce labor.
• Delivery should be effected if there is evidence of fetal compromise or oligohydramnios.

The following recommendations are based primarily on consensus and expert opinion (Level C):

• Despite a lack of evidence that monitoring improves perinatal outcome, it is reasonable to initiate antenatal surveillance of postterm pregnancies between 41 weeks (287 days; estimated delivery date [EDD] +7 days) and 42 weeks (294 days; EDD +14 days) of gestation because of evidence that perinatal morbidity and mortality increase as gestational age advances.
• Many practitioners use twice-weekly testing with some evaluation of amniotic fluid volume beginning at 41 weeks of gestation. A nonstress test and amniotic fluid volume assessment (a modified biophysical profile [BPP]) should be adequate.
• Many authorities recommend prompt delivery in a postterm patient with a favorable cervix and no other complications.

Definitions:

Grades of Evidence:

I: Evidence obtained from at least 1 properly designed randomized controlled trial.

II-1: Evidence obtained from well-designed controlled trials without randomization.

II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than 1 center or research group.

II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence.

III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of Recommendation

Level A — Recommendations are based on good and consistent scientific evidence.

Level B — Recommendations are based on limited or inconsistent scientific evidence.

Level C — Recommendations are based primarily on consensus and expert opinion.

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

Accurate assessment of gestational age and diagnosis of postterm gestation, as well as recognition and management of risk factors, may reduce the risk of adverse sequelae. Antenatal surveillance and induction of labor are 2 widely used strategies that theoretically may decrease the risk of an adverse fetal outcome.

• Overall, the medications (prostaglandin E₂ [PGE₂; dinoprostone] and PGE₁ [misoprostol]) were well tolerated with few reported side effects. Higher doses of PG (especially PGE₁) have been associated with an increased risk of uterine tachysystole and hyperstimulation leading to nonreassuring fetal testing results
• The risk of uterine rupture does not appear to increase substantially after 40 weeks of gestation, but the risk appears to be increased with labor induction with PG or pitocin regardless of gestational age.

These guidelines should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.

An implementation strategy was not provided.

Getting Better
Staying Healthy

Effectiveness
Timeliness

• American College of Obstetricians and Gynecologists (ACOG). Management of postterm pregnancy. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2004 Sep. 8 p. (ACOG practice bulletin; no. 55). [69 references]

Not applicable: The guideline was not adapted from another source.

1997 Oct (revised 2004 Sep)

American College of Obstetricians and Gynecologists - Medical Specialty Society

American College of Obstetricians and Gynecologists

American College of Obstetricians and Gynecologists (ACOG) Committee on Practice Bulletins-Obstetrics

Not stated

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American College of Obstetricians and Gynecologists (ACOG). Management of postterm pregnancy. Washington (DC): American College of Obstetricians and Gynecologists; 1997 Oct. 6 p. (ACOG practice patterns; no. 6).

None available

This summary was completed by ECRI on April 14, 1999. The information was verified by the guideline developer on June 11, 1999. This NGC summary was updated by ECRI Institute on August 1, 2007. The updated information was verified by the guideline developer on September 10, 2007.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.