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AOM Clinical Practice Guideline – Pregnancy Beyond 41 Weeks

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AOM Clinical Practice Guideline – Pregnancy Beyond 41 Weeks CLINICAL PRACTICE GUIDELINE10 Management of the UNCOMPLICATED PREGNANCY BEYOND 41+0 WEEKS GESTATION February 2010 Clinical Practice Guideline No.10 Management of the UNCOMPLICATED PREGNANCY BEYOND 41+0 WEEKS’ GESTATION AUTHORS AOM STAFF Julie Corey, RM MHSc Suzannah Bennett, MHSc Tasha MacDonald, RM MHSc Cindy Hutchinson, MSc Bobbi Soderstrom, RM CONTRIBUTORS Clinical Practice Guideline Subcommittee ACKNOWLEDGEMENTS Elizabeth Darling, RM MSc, Chair Kristen Dennis, RM Cheryllee Bourgeois, RM Ontario Ministry of Health and Long-term Care Corinne Hare, RM Ryerson University Midwifery Education Program Jenni Huntly, RM Paula Salehi, RM The Association of Ontario Midwives respectfully Lynlee Spencer, BSc acknowledges the financial support of the Ministry of Vicki Van Wagner, RM, PhD (c) Health and Long-Term Care in the development of this Rhea Wilson, RM guideline. INSURANCE AND RISK MANAGEMENT The views expressed in this guideline are strictly those PROGRAM STEERING COMMITTEE of the Association of Ontario Midwives. No official ‘Remi Ejiwunmi, RM, Chair endorsement by the Ministry of Health and Long-Term Abigail Corbin, RM Care is intended or should be inferred. Elana Johnston, RM Carolynn Prior van Fraassen, RM Lisa M Weston, RM This document may be cited as: Postdates CPG Working Group. Association of Ontario Midwives. Management of the Uncomplicated Pregnancy Beyond 41+0 Weeks’ Gestation. February 2010. The AOM is committed, through our statement on Gender Inclusivity and Human Rights, to reflect and include trans, genderqueer and intersex communities in all aspects of our work.In this document, there are references to sources that use gendered language to refer to populations of pregnant and birthing people. In order to accurately represent these sources, we may have maintained gendered language. We support research and knowledge translation that engages and reflects the entire childbearing population. This guideline was approved by the AOM Board of Directors: February 17, 2010 Management of the UNCOMPLICATED PREGNANCY BEYOND 41+0 WEEKS GESTATION Statement of purpose used to provide more detail on individual topics as they The goal is to provide an evidence-based clinical practice related to postdates pregnancy: antenatal monitoring, guideline (CPG) that is consistent with the midwifery fetal movement counting, evening primrose oil and philosophy of care. Midwives are encouraged to use this gestational age calculation. Older publications were CPG as a tool in clinical decision-making. accessed to include seminal randomized controlled trials, commonly cited sources for incidence rates or studies Objectives that had significant impact on clinical practice. Evidence To provide a critical review of the research literature was graded using the Canadian Task Force on Preventive on uncomplicated pregnancy at and beyond 41+0 Health Care grading system. (1) weeks’ gestation and beyond, as well as to provide recommendations regarding management options. Review: Evidence relating to the following will be discussed: This guideline was reviewed using a modified version of the AGREE instrument (2), the AOM’s Values-based • Factors contributing to an increased risk of Approach to CPG Development (3), as well as consensus postdates pregnancy of the AOM CPG Sub-committee, the Insurance and Risk • Effective interventions for reducing the rate of Management Program, and the AOM Board of Directors. postdates pregnancy • Impact of postdates pregnancy on maternal and Abbreviations neonatal outcomes • Management options for postdates pregnancy. CI confidence interval CS caesarean section Outcomes of interest BMI body mass index 1. Maternal outcomes: rate of caesarean section, BPP biophysical profile instrumental delivery, morbidity, satisfaction with care EDB estimated date of birth 2. Neonatal outcomes: perinatal mortality, perinatal LMP last menstrual period morbidity MAS meconium aspiration syndrome MSAF meconium stained amniotic fluid NNT number needed to treat Methods: OR odds ratio A search of the Medline database and Cochrane RR relative risk library from 1994-2009 was conducted using the key T1 first trimester words: prolonged pregnancy, postdates pregnancy, T2 second trimester postterm pregnancy. Additional search terms were This guideline reflects information consistent with the best evidence available as of the date issued and is subject to change. The information in this guideline is not intended to dictate a course of action, but inform clinical decision-making. Local standards may cause practices to diverge from the suggestions within this guideline. If practice groups develop practice group protocols that depart from a guideline, it is advisable to document the rationale for the departure. Midwives recognize that client expectations, preferences and interests are an essential component in clinical decision-making. Clients may choose a course of action that may differ from the recommendations in this guideline, within the context of informed choice. When clients choose a course of action that diverges from a clinical practice guideline and/or practice group protocol this should be well documented in their charts. Management of the Uncomplicated Pregnancy Beyond 41+0 Weeks Gestation 3 KEY TO EVIDENCE STATEMENTS AND GRADING OF RECOMMENDATIONS, FROM THE CANADIAN TASK FORCE ON PREVENTIVE HEALTH CARE Evaluation of evidence criteria Classification of recommendations criteria I Evidence obtained from at least one A There is good evidence to recommend the properly randomized controlled trial clinical preventive action II-1 Evidence from well-designed controlled trials B There is fair evidence to recommend the without randomization clinical preventive action II-2 Evidence from well-designed cohort C The existing evidence is conflicting and (prospective or retrospective) or case-control does not allow to make a recommendation studies, preferably from more than one for or against use of the clinical preventive centre or research group action; however, other factors may influence decision-making II-3 Evidence obtained from comparisons C The existing evidence is conflicting and between times or places with or without the does not allow to make a recommendation intervention. Dramatic results in uncontrolled for or against use of the clinical preventive experiments (such as the results of treatment action; however, other factors may influence with penicillin in the 1940s) could also be decision-making included in this category III Opinions of respected authorities, based on D There is fair evidence to recommend against clinical experience, descriptive studies, or the clinical preventive action reports of expert committees E There is good evidence to recommend against the clinical preventive action L There is insufficient evidence (in quantity or quality) to make a recommendation; however, other factors may influence decision-making Reference: (1) 4 AOM Clinical Practice Guideline 16 INTRODUCTION Pregnancy at 41+ weeks’ gestation is seen often in any pregnancy after 42+0 weeks (or synonymous with midwifery practice. Though it is generally a normal and postterm). (WHO 1977, FIGO 1986, cited in (4)) healthy occurrence associated with good outcomes for Considerable confusion arises, however, as ‘postterm’, clients and infants, pregnancy at 41+ weeks has been ‘postdates’ and ‘prolonged’ pregnancy tend to be used associated with increased risks of meconium stained interchangeably in research literature and textbooks, as amniotic fluid (MSAF), meconium aspiration syndrome well as by health care providers. The lack of precision (MAS), shoulder dystocia and stillbirth. Determining in the use of the terms associated with pregnancies the best method of calculating an estimated date of birth that pass the EDB is widespread and may lead to (EDB), effective monitoring of fetal well-being, and misunderstanding as described by Murray Enkin: if, when and how to intervene to initiate labour are all important aspects of postdates pregnancy management. “Semantic problems have also contributed Midwives providing care for pregnancy at 41+ weeks’ to the confusion in understanding of gestation aim to avoid unnecessary intervention while postterm pregnancy. The words ‘postterm,’ facilitating the best possible outcomes for clients and ‘prolonged,’ ‘postdates’ and ‘postmature’ their infants. are all used as synonyms but are laden with different evaluative undertones.” (5) Discussing and implementing a plan for management of pregnancy at 41+ weeks is part of the informed choice Further, this ambiguity in the use of terms associated process. In order to facilitate client decision-making with postdates pregnancy makes “accurate compounding regarding pregnancy at 41+ weeks, midwives need to be of the qualitative data” difficult. (6) aware of the risks and benefits of interventions such as Where possible, the gestational age upon which research induction of labour, as well as of expectant management. studies based their results will be specified in this CPG, but due to inconsistencies in the way data was collected, Definition of Terms gathered or reported, this level of accuracy in reporting According to the internationally recommended outcomes according to gestational age is not always definitions endorsed by the World Health Organization possible. (WHO) and the International Federation of Gynecology and Obstetrics (FIGO), ‘postterm’ pregnancy is defined Using specific language when communicating with as pregnancy lasting 42+0 weeks (≥ 294 days) or other health care providers
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