Posted by My OB said WHAT?!?.
Apr
19
Posted by My OB said WHAT?!?.
Thoughtful Thursday! The Risk Of Stillbirth Really Increases At About 44 Weeks.”
“The risk of stillbirth really increases at about 44 weeks.”-OB to mother inquiring about risks of continuing pregnancy past 42 weeks.
There are 27 comments to this post.
This is mine! I was 41+5 (with not one “sign” of labor-baby still high, cervix completely closed, zero contractions…)at this appointment and had a repeat c-section scheduled for two days later. The next day (day before surgery) I called and cancelled. My doctor just asked me to come in for a BPP in a day or so. I started laboring later that day and had a successful VBAC at 42 weeks-just hours after he would have been born in the OR anyway!!
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Everything I can find says the risk increases “after 42 completed weeks of pregnancy”. So at 42+1.
Does anyone have a link for me?
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Jane Reply:
April 20th, 2012 at 4:40 am (Quote)
I don’t have a link, but the way I’ve seen it described is as a bell curve. A baby has the highest risk of a successful, complication-free birth at 40 weeks, followed by a slight decline in the times around it on both sides. THen it drops sharply on both sides (risk of stillbirth, shoulder dystocia, and other complications on the long-side, and on the premature side you get the complications of prematurity.)
The question is not where “risk increase” but at what point the mother no longer feels comfortable with the risk. Risk increases in a car when you get on the highway, but that doesn’t mean people don’t take highways. It does mean people take certain precautions when they’re on the highways. Well, the same thing is true for birth. There’s not a demarcation of “risk free birth” and then a sudden sharp line where “risk starts.” There are always risks.
So many doctors will say the risk increases at 42 weeks. Other doctors say the risk increases right at the due date. And this one says at 44 weeks. And…they’re all correct to some degree.
The question we have to ask, then, is why a doctor who says there’s a high risk to delivering a baby a 42 weeks is perfectly fine with delivering a baby at 38 weeks, when the numbers are about the same of complicated/uncomplicated birth. And if the doctor has heart palpitations just at the thought of delivering at 44 weeks, then the doctor should be doing everything modern medicine can offer in order to stop a baby from being born at 36 weeks.
But we don’t see that, do we?
So if the authors of whatever article are saying “risk increases at 42 weeks,” that’s just the point where they themselves feel it’s too risky to justify continuing the pregnancy. But it’s a sliding scale, and the person who’s assuming the risk should get to make the decision.
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Details Reply:
April 20th, 2012 at 5:40 am (Quote)
I would start at ACOG since Chelsie mentioned it. You also have to remember that the risks increase and then the risks increase again. It is the slope of the curve that is important. The recommended advice is do nothing until 42 weeks and then monitor, and then you can panic at 44. Large numbers of CYA OB’s panic at 40 which is the problem. And of course the question always comes up 40 weeks from when exactly?
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Nicole Reply:
April 20th, 2012 at 6:58 am (Quote)
http://mail.ny.acog.org/website/PtSafety/PB55.pdf
That’s ACOG’s most recent practice bulletin on postterm pregnancy, which basically says after 40 weeks closer monitoring is advised and women with favorable cervices stand to benefit from being induced, particularly with prostaglandins, and it did address misdiagnosed postterm based on poor dating practices.
I suppose that really the risk versus benefits need to be weighed for each woman individually, and maybe this mom felt the sharp rise in stillbirth at 43 weeks was preferable to the sharp rise in cesarean section with induction. But it appears as though she wasn’t being fully informed to me, because the risk DOES rise sharply at 43 weeks.
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Details Reply:
April 20th, 2012 at 8:55 am (Quote)
If you read the pink link from Alana you will see that this was a VBAC and induction was not an option. The other option was to consent to an elective c-section with no TOL. She choose to give herself two more days and the doctor choose to encourage her. I don’t have a problem with that.
I understand your persuit of the most reliable and up-to-date research. But the “it appears as though she wasn’t being fully informed to me” comment is a rush to judgement because you know this site gives as little detail as possible in the original post and that you have to read the pink link to really know what the facts are. And the pink link had been up for 12 hours before you made that last comment. So let’s pay attention to the details shall we 
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Nicole Reply:
April 20th, 2012 at 12:48 pm (Quote)
I did read the pink. She didn’t say she had been informed of the increased risk starting at 42+1.
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Alana Reply:
April 20th, 2012 at 6:52 pm (Quote)
The conversation continued beyond this, but my impression was it was “thoughtful” because it wasn’t the “dead baby card” that most OB’s use. Also, you’ll notice that I left this visit with the surgery still planned and then did more research over the next 24 hours before deciding to cancel my surgery.
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Nicole Reply:
April 20th, 2012 at 7:56 pm (Quote)
I’m sorry, Alana, I didn’t mean to imply that your doctor was not being thoughtful. I think he did exactly the right thing. I just don’t think evidence supports his statement that risk doesn’t increase until 44 weeks.
I’m so happy that you went on to have your VBAC! I bet it felt amazing!
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Toni Reply:
April 21st, 2012 at 10:17 am (Quote)
This is where I think written words fail us, lol. I read it with the emphasis on *really*. As in – the risk doesn’t *dramatically* increase until 44 weeks. Now I’d read/heard that the risk dramatically increases at 43 weeks (or after 42 weeks), but nevertheless, I agree with the sentiment that your uterus won’t suddenly explode at 42w 0d, lol. There is a slight increase in risk after 40 weeks, slightly more after 41, with the risks rising more shrply as the days/weeks wear on. I don’t think this doc meant that there is *no* additional risk until week 44, just that, at least from his perspective, the risks don’t rise dramatically until that point.
Not sure if that helps, but that was my take on it.
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Teresa Reply:
April 20th, 2012 at 6:05 am (Quote)
This only goes through 43 weeks but shows a peak of risk at 40 weeks before the risk starts to decrease again: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28178/table/TN0x8a59820.0x9aa1e68/
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Nicole Reply:
April 20th, 2012 at 6:29 am (Quote)
That chart shows that the risk drops at 40 weeks (compared to all weeks listed prior), rises a little at 41 weeks, again at 42 weeks and then sharply at 43 weeks. Which is consistent with the rest of my research.
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Nicole Reply:
April 20th, 2012 at 6:50 am (Quote)
This is ACOG’s most recent practice bulletin on postterm pregnancy.
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Details Reply:
April 20th, 2012 at 9:38 am (Quote)
How exactly do you consider 2.29 still birth per 1000 ongonging pregnancies at 37 weeks, then 1.61 still births per 1000 ongoing pregnancies at 40 weeks, and then back up to almost as high as 37 week with 2.12 still births per ongoing pregnancies at 43 weeks to be a sharp rise?!? That is per 1000. If going to 43 weeks was so freaking dangerous I would except at least a 10% death rate. How many times have we been told YOUR BABY WILL DIE. (not might, Will)If it was 10% that would be 100 per 1000! Do you understand?
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Details Reply:
April 20th, 2012 at 12:22 pm (Quote)
Upon reviewing the mathematics of this little report according to the rule of signifcant digits there are only two significant digits in most of these calcualtion not 3 as shown and in the 43 weeks you only get to site one significant digit. Translation: those numbers get rounded to 2.3, 1.6 and 2 because the sample sizes are so small. So there is no mathematical significance here! Tacking that extra decimal makes it look all exact and precise, but mathematically it is wrong!
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Nicole Reply:
April 20th, 2012 at 1:05 pm (Quote)
I agree that most doctors are alarmist about postdates. It’s ridiculous. The BMJ article quoted above me has these rates (per 1000 continuing pregnancies):
35w: 2.97
36w: 2.68
37w: 2.29
38w: 2.05
39w: 1.75
40w: 1.61
41W: 1.78
42w: 1.94
43w: 2.12
Lowest risk of stillbirth is at 40 weeks here. That is a significant rise.
The point is that the risk of mortality or morbidity from interventions become lower than the risk of mortality or morbidity if pregnancy is continued. It’s not “so freaking dangerous” it just improves outcomes to intervene at some point. That’s the whole point of intervention, and if it saves just a fraction of babies who would not otherwise survive, isn’t it worth it? And yes, I realize that is a slippery slope, that’s why we have to be careful what providers we hire.
Don’t get me wrong, here, I am a home birthing mama, an aspiring midwife, and don’t support routine intervention because some magic number has been reached on a calendar. I LIKE that this doctor just recommended a BPP and went for the VBAC. But the numbers don’t really lie and closer monitoring IS warranted after 42 weeks, because there IS a rise in fetal demise at that point. And nothing in the quote or in the OP’s backstory says that she was informed of that.
The numbers get so small because so few pregnancies go beyond 42 weeks. Nature knew what She was doing, and 95% of women have their babies before 43 weeks. I trust Nature’s design for at least 95% of women. But there is a small percentage where something goes wrong, and that’s the whole point of having a care provider and interventions.
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Details Reply:
April 24th, 2012 at 1:47 pm (Quote)
You still aren’t getting the math. The nubmers do lie because the rules of statistics and mathematics were ignored. The corrected numbers would be
35w: 3.0
36w: 2.7
37w: 2.3
38w: 2.1
39w: 1.8
40w: 1.6
41W: 1.8
42w: 1.9
and
43w: 2
They don’t get to claim 3 significant digits!
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Hey! An OB that got the ACOG memo.
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