Going over 40 weeks pregnant

Going Over 40 Weeks Only around 3-5 per cent of women will give birth on their due date. Most women go into labour a week either side of their due date, but some women can go over. Giving birth just before or just after week 40 is normal, as there is some flexibility to the 40-week due date as there are two measurements of pregnancy: gestational weeks and fertilisation weeks. Gestational weeks refers to when your last period started, whereas fertilisation weeks refers to when conception occurred, usually two weeks after your last period, which gives you two weeks extra, until week 42. If you conceived using assisted reproductive medicine such as in vitro fertilisation (IVF), then your due date is the same as if you conceived naturally and is still calculated from your last period or when you had your down regulating bleed if you underwent a long IVF protocol. This calculation uses gestational weeks. Around 20 per cent of pregnancies will have their due date changed after their first trimester scan, especially if IVF was used. Accurate measuring of your baby at this point is important as it will then determine if medical intervention is required to bring on labour. If you are over 35 years old, your midwife or obstetrician may recommend procedures to help bring on labour at weeks 38-40. This reasoning comes from research which has shown inducing delivery at week 40 resulted in: - A 48 per cent lower risk of meconium aspiration syndrome (trouble breathing). - A 67 per cent lower risk of death of the baby. - A 75 per cent lower risk of stillbirth. Being medically induced does carry an increased risk of deliveries requiring the assistance of a surgical instrument, such as forceps, or an emergency caesarean section, and can affect the baby's respiratory system. However, research found that being induced at week 41 resulted in: - A 43 per cent lower risk of meconium aspiration syndrome. - A 6 per cent lower risk of emergency caesarean section. - A 76 per cent lower risk of death of the baby. - A 82 per cent lower risk of stillbirth. If you feel that you want to carry your pregnancy past week 40, then you should discuss this with your midwife, doula or obstetrician. There are several factors that need to be taken into account when deciding whether to carry on past week 40, for example: - Is baby facing head-down or are they breeched? - Is this your first pregnancy? - The position of the placenta. - The size of your baby. - The amount of amniotic fluid in your uterus. - Your age. - Y our health, for example any gestational diabetes, hypertension or pre-eclampsia. When carrying on past week 40, it is important to monitor both the baby and your placenta. You may be able to request antenatal foetal testing, which involves a non-stress test (NST, see page 37) or a biophysical profile. If you are under 35 years old, have no health issues, the baby is not too big and is not distressed and your placenta is intact, then you may be able to carry on past week 40 without any problems.

On this page

Labour Induction
Natural induction
Natural herbs
Acupuncture
Medical interventions
Membrane sweep
Medical induction

Labour Induction

A labour induction is used to bring on a vaginal delivery. It can be started either naturally via acupuncture or the taking of natural herbs or it can be medically induced. Every year, one in five labours are medically induced in the UK, the US and Canada. Labour can be induced if your baby is past term, there is any potential risk to the mother or baby, if the mother is older than 35 or if you conceived using IVF. Health conditions such as high blood pressure, gestational diabetes, pre-eclampsia, intrauterine growth restriction (IUGR) or if your waters have broken but labour has not started, can result in being medically induced. Often labour is induced before there is any apparent risk to the baby as a preventative measure.

Natural induction

A natural induction is gentler and can result in fewer complications. It helps to bring on labour if the baby is ready. Remember that even though your baby is inside you, they are a little person and will only come if they are ready to take their first breath. Forcing them to come out early can cause complications for you and them. Therefore, trying naturally can be a better course of action to begin with. There are several natural ways to help bring on labour. Let's look at each of them.

Natural herbs

There are several natural herbs and oils that can be used to help bring on labour. I would recommend consulting with a qualified and accredited herbalist before taking any herbs during pregnancy. Bethroot (trillium erectum): Bethroot has a long history of being used to induce labour amongst Native Americans and early settlers in North America. It is commonly used to stimulate uterine contractions to induce labour and encourage a stalled labour. The recommended daily dose during pregnancy is 2-3ml taken two to three times per day.

Black cohosh (rhizoma cimicifugae): Black cohosh has a long history of being used to induce labour amongst Native Americans and is recommended by some midwives. It is believed that black cohosh has an effect on oestrogens by helping to regulate and lower levels of oestrogens, thereby allowing oxytocin to initiate labour contractions. The recommended dose to bring on labour is two dropperfuls sublingual plus one dropperful every four hours until contractions start.

Castor oil (ricinus communis): Castor oil has been used to induce labour since the ancient Egyptian times. It is often recommended by midwives to help bring on labour. It may work on prostaglandins, helping to bring on labour and ripen the cervix and is considered safe to use. As castor oil is a laxative, it may cause stomach upset and loose bowels. The recommended daily dose to induce labour is 1-2 tablespoons with meals.

Cottonroot (gossypium thurberi): Cottonroot bark is good at inducing labour as it makes tissues that respond to oxytocin more sensitive to the hormone, thereby aiding contractions. The recommended daily dose to induce labour is 30-60 drops under the tongue up to every half hour. Use an organic tincture as pesticides are often sprayed on to cotton crops.

Dong quai (radix angelica sinensis): Dong quai (dang gui) is native to China and Japan. It is commonly used in Chinese and Japanese herbal medicine. In late pregnancy it can help to ripen the cervix, thereby aiding labour. The recommended daily dose to ripen the cervix is 200mg three times a day. Clary sage (salvia sclarea): Clary sage is a plant native to Italy, Syria and Southern France. It is used in aromatherapy and is considered safe to use in pregnancy from week 37 if your baby is head down and engaged. It can increase levels of oxytocin, thereby helping to bring on contractions. You can either put a few drops on to a dry cloth or flannel and inhale the aroma or soak a few cotton balls in the oil and put them under your pillow at night.

Evening primrose (oenothera biennis): Evening primrose oil is commonly given by midwives to trigger cervical ripening. Evening primrose oil can be given either orally or vaginally to help ripen the cervix and is considered safe to use in late pregnancy. The recommended dose of evening primrose oil to induce labour is 500mg orally three times per day for one week beginning at week 37 and then 500mg orally once per day until labour begins.

Motherwort (leonorus cardiaca): Motherwort soothes and calms the nervous system,while balancing the hormones of the endocrine system, making it an excellent remedy to induce labour and calm the mother. Motherwort is used a lot in Chinese herbal medicine under the name of Yi Mu Cao. The recommended dosage in pregnancy is 30-60 drops of tincture under the tongue per day.

Partridge berry (mitchella repens): Partridge berry has a long history amongst the Native Americans to tone and nourish the uterus and help prevent a miscarriage. However, modern use stipulates to use partridge berry from week 37 onwards to stimulate the uterus into labour.

Raspberry leaf (rubus idaeus): Raspberry leaf has a long history of use in helping to bring on contractions and labour and is recommended by some midwives. It works on the smooth muscle of the uterus and is safe to take from week 32 onwards. It can reduce the duration and pain of labour. It is advisable to stop taking raspberry leaf if you start having strong contractions or are taking metformin; antidepressants; codeine; aminophylline; ephedrine and atropine. The recommended daily dose during pregnancy is one cup or 800-1200mg from week 32.

Shepherd's purse (capsella bursa-pastoris): Shepherd's purse helps

increase tissue sensitivity to the labour hormone oxytocin. One teaspoon of the fresh, whole-plant tincture under the tongue or sipped in a cup of tea should help induce labour or deliver a sticky placenta. Multiple doses can be given and is considered safe to take. Shepherd's purse combines well with cottonroot bark.

Valerian (valeriana officinalis L.): Valerian is a natural relaxant and can be used when entering labour. When starting labour, some women can become anxious and stressed, which can affect the release of oxytocin, the hormone that causes contractions, causing labour to stop. Valerian can help women to relax, allowing the hormone oxytocin to be released and contractions to continue. It is considered safe to use during labour. The recommended dose during labour is 120-200 mg, three times per day.

These natural herbs can be used alongside other forms of therapy to help bring on labour naturally, such as acupuncture.

Acupuncture

Acupuncture is a safe and gentle way to help bring on labour naturally. I use acupuncture for induction purposes at my clinic with good results. Acupuncture can gently nudge the baby out naturally but cannot push them out. A medical induction is more like a push.

Acupuncture can help to ripen the cervix and reduce stress and anxiety that could be reducing levels of oxytocin. A review published in 2009 concluded that acupuncture is beneficial in labour induction. I would recommend starting acupuncture treatment before needing to be induced, from week 35, as it helps to prepare your body by regulating hormones, reducing anxiety and stress, and ripening the cervix, which not only helps to bring on a natural labour but also helps to shorten the duration of labour and reduce pain levels.

Medical interventions

There are several medical interventions that can be used to bring on labour. Some are gentler than others.

Prostaglandin E2 (PGE2)

This involves taking a medication that contains prostaglandin E2. The medication can be taken either orally or inserted into the vagina. However, taking it orally can upset the stomach. Therefore, the preferred method is to insert a tablet (or pessary) or gel into the vagina. This tablet or gel contains the medication dinoprostone. Dinoprostone should not be used if you suffer from asthma, glaucoma or a severe kidney, respiratory or liver disease.

Induction of labour may take several hours as the cervix takes time to dilate and open up fully. The cervix generally dilates by around 1cm for every one hour. If you have a vaginal tablet or gel, you may be allowed to go home while you wait for it to work. You should contact your midwife or obstetrician if:

- Your contractions begin and are every three minutes, which means you are ready to deliver your baby.

- You have not had any contractions after six hours and will therefore need more medication.

If you have a controlled-release pessary inserted into your vagina, it can take around 24 hours to work. If you do not have contractions after 24 hours, you may be offered another dose.

Membrane sweep

A membrane sweep (stripping) is normally offered at around week 40. It involves the midwife or obstetrician inserting their fingers into your vagina to reach the cervix (neck of your womb), and then into your cervix to the uterus where they rotate their finger to strip off the lower segment membranes. This procedure is often uncomfortable and painful. There might be some bleeding afterwards, which is normal. This action should separate the membranes of the amniotic sac surrounding your baby from your cervix. This separation releases prostaglandins, which should hopefully kick-start your labour. If labour does not start after a membrane sweep, you may be offered a medical induction.

Medical induction

A medical induction is offered to women who do not go into labour by week 41 or to those women considered high risk, although what constitutes high risk varies from country to country and from obstetrician to obstetrician.

If you have to be induced, you will go into the hospital's delivery ward, where a midwife will monitor you and your baby. Pads will be placed on your abdomen to monitor the baby's heart rate.Unfortunately, this will not allow you to move around and get comfortable, which may mean needing pain control medication.

A medical induction is the use of a drip containing the hormone oxytocin. Oxytocin is the hormone that causes your abdomen to contract, which pushes your baby out. Once the medical induction starts to work, labour should proceed normally, but in a small minority it can take 24-48 hours.

Research has shown that having acupuncture treatment at the time of labour reduces the dose of oxytocin needed to induce labour and the duration of labour. Probiotics that contain lactobacillus reuteri have been shown to increase levels of oxytocin naturally. Using this alongside acupuncture can be beneficial for both you and your baby.

Medical inductions using oxytocin are usually more painful than a normal vaginal delivery as artificially high levels of oxytocin are poured into the body, which results in stronger contractions than normal that force the baby out. Women who are medically induced are therefore more likely to ask for strong pain relief medications, such as an epidural. Medical inductions may also stress the baby as they are pushed out quickly. Mothers who are medically induced can have lengthy recovery times because a medical induction allows for less time for the mother's body to adapt, which can be traumatic for her body.

Women who are induced are also more likely to need an assisted delivery, where forceps or ventouse suction is used to pull the baby out. This is probably due to the speed of delivery as it does not allow your vagina to adapt quickly enough and stretch open. You can aid your vagina's ability to stretch by training it several weeks beforehand by self-massaging or using either an Aniball or Epi-No balloon (see page 200).

Being induced is a tough decision for most mothers who want things to be natural and have a strong maternal belief that the baby will come when they are ready. Recent research has shown that it is the baby who initiates labour by releasing a protein from their lungs. This signifies that they are ready to breathe, the most important of all survival skills. Inducing before this protein is released can mean the baby having respiratory problems. Research has shown that the majority of natural births occur at 4 a.m., the time when the lung acupuncture channel is active. You may be able to request a foetal lung maturity test to see if your baby's lungs are ready to breathe. This test involves taking a sample of amniotic fluid (amniocentesis) to measure the lecithin-sphingomyelin ratio (L/S ratio). Mature foetal lungs have a L/S ratio between 2.0 and 2.5, whereas immature lungs have a L/S ratio of less than 2.0.

Most women will follow their obstetrician and midwife's advice and be induced. The baby's lungs can carry on developing after birth and they should grow out of any initial respiratory problem should they have them. This is often a better option than facing other possible negative outcomes should the mother wait.

Part Six

Labour Care

Going through labour for the first time can be daunting for a lot of women. In this part, I will go through what will happen during labour in order for you to be mentally prepared. By being well informed, your mind can let go and allow your body to naturally deliver your baby. Remember that you have millions of years of evolution behind you and that your body is designed to give birth.

My Pregnancy Guide

My Pregnancy Guide by Dr (TCM) Attilio D’Alberto is a comprehensive week-by-week guide to a healthy pregnancy and labour, based on over 750 peer-reviewed research studies and 20 years of clinical experience. It blends the latest evidence-based science with the proven theories of traditional Chinese medicine to give you everything you need for a confident, well-supported pregnancy and a positive birth experience.

The book covers pregnancy week by week, an optimal pregnancy diet and supplements, how to reduce your baby’s risk of developing autism, managing complications including gestational diabetes and pre-eclampsia, preparing for labour, pain relief options, acupuncture for labour induction, natural herbs to support birth, and postnatal recovery. Available in paperback, Kindle and ebook from Amazon, Waterstones and all major bookshops.