Ep 147: Let’s Talk About Due Dates

Ep 147: Let’s Talk About Due Dates

Nicole: In this episode, you are going to learn all about your due date. Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it.

Nicole: Hello there. Welcome to another episode of the podcast. This is episode number 147. I am so glad that you are spending some of your time with me today. Alright, so today's episode is all about due date. And this is an episode I did it like almost three years ago and like towards the beginning of the podcast, and it was definitely time to update it. So you need to know about your due date because your due date is really important. All of the decisions that are made during pregnancy revolve around your due date. So it is really crucial that we get it right. So in this episode, you are going to learn why your due date is important, how it is best determined, like what is the best way to determine your due date? Why it's really important to understand that due date is an estimate.

Nicole: I actually hate the term due date. And then in this episode, which I'm adding that wasn't in the first episode, you're gonna learn about what happens when you go past your due date, because this is a common question that I get. So you learn some definitions about going past your due date. You learn the risk associated with going past your due date. And then I will end with what your options are for when you go past your due date or when you get near your due date. All right, now, before we get into the episode, let's do a listener shout out. This is from Dena dancer and she says, great find I'm at 32 weeks of my first pregnancy and just found this podcast. I find it very informative, practical, and relevant, and will keep listening. I've shared it with my husband as well. We have been reading books upon books and find the podcast offers specialist topics of focus and is more personal. Well, I am so, so glad that you enjoy the podcast.

Nicole: These are all of the reasons why I created it. So folks can have informative information. It's evidence based, it's comprehensive, holistic approach, also practical and re relevant. So I am glad that you will keep listening and that your husband is listening too. Now, if you want to get more beyond what I just have on the podcast, definitely join my email list. On my email list, I offer exclusive discounts there that I don't offer anywhere else. Okay. So you can join my email list at drnicolerankins.com/email, never any spam or anything like that. And I certainly don't sell your information. I also send like helpful tips and information in the email. So if you're like someone who's not on social media, um, which we all need to do less of these days being on my email list is a great way to stay in contact with me and still get great information in between podcast episodes. So join the email list to drnicolerankins.com/email. Again, you'll get those exclusive discounts there as well.

Nicole: All right. So let's talk about your due date. So your due date is more than just giving you an idea of when your baby is going to be born. An accurate estimate of your due date is absolutely critical during your pregnancy because management decisions during pregnancy are highly, highly influenced by how developed your baby is. And the baby's development is tied to the gestational age and the gestational age is determined by the due date. So really so many decisions revolve around the due date. For example, determining whether or not you are preterm determining if the pregnancy is post term, and I'm gonna define the post term, um, definition in a little bit in the episode. Also certain tests are done at certain times in pregnancy in order to get them most accurate results like screening for gestational diabetes. There's some genetic tests that need to be done at a certain point in pregnancy, accurate due date also reduces the chances of induction.

Nicole: So it's really, really important that we have an accurate date in your pregnancy, because if the dates are wildly off or really inaccurate, then we can be making decisions and potentially end up, for example, say inducing someone's labor, because we think the baby is small. When in actuality, the due date was inaccurate and actually the baby wasn't small, the baby was just earlier in the pregnancy than we thought based on the due date. So getting an accurate due date is super duper important. Now, one of the things that I want you to realize about due date is that it is an estimate, okay. It is an estimate. It's an estimate. It's an estimate. I see so many people get tied to this specific date and it is very much so an estimate actually only about 4% of women will deliver on that actual due date.

Nicole: Now, part of it is because just some of the limitations we have that are, you know, where we can guess when a baby is gonna be born, but also there's just a lot of natural biologic variation in the way babies develop. So it's really hard to say that this is the date that your baby is going to come because there's a lot of variation in that I actually wish we would stop giving a due date and instead give a range of dates that we expect that you'll deliver. You know, even if we gave like a seven day range, that would actually be pretty accurate, a few seven to 10 days, a few days before, a few days after that due date is a more accurate estimate of when you are most likely to go into labor and not on that specific due date. Okay. So how do we estimate the due date? Traditionally before ultrasound, we used to estimate the due date by adding 280 days from the first day of the last menstrual period or 266 days from the date of conception. So from the date of your last menstrual period, you don't actually get pregnant until you ovulate after that. So usually it's about two weeks after that. So that's why there's a difference in the days between 280 and 266, because the date of conception is going to be after the last menstrual period. Now this method is flawed because it assumes that all women have regular menstrual cycles that are 28 days, and that ovulation occurs on the 14th day. So this doesn't take into account that women also may not accurately remember their last menstrual period. I mean, sometimes, you know, you have an idea like, oh, I think it was this day, or I know it was during this week.

Nicole: Some of us don't necessarily track the exact date. So you may not know the exact date. And again, so many of us are not on like regular 28 day cycles. I would probably guess that most of us actually are not on regular 28 day cycles. We may be on regular cycles, but it may be 29 or maybe 27 or maybe some little bit of variations. That's why that method isn't always necessarily the best. Okay. So actually the best estimate of the delivery date or due date is based on ultrasound performed before 22 weeks, zero days of pregnancy, and actually crown rump length is like what it sounds like it's a measurement from the top of the, the crown of the baby's head to the rump the, the bottom measured in the first trimester. So up to 14 weeks is the most accurate ultrasound method of determining the due date.

Nicole: It is more accurate than any other ultrasound done at any other point in pregnancy. So that's why a lot of offices do ultrasound in the first trimester, because that is going to be the most accurate method that we have of determining due date. Now, once we get an ultrasound estimate of your due date, then we compare it to the due date that we got based on your last menstrual period. And then we come up with a final date. So if the ultrasound date differs from the date based on your last menstrual period, by anywhere from seven to ten days, depending on when the ultrasound was done, then we use the due date based on ultrasound. Okay. So if those two things differ by seven to 10 days, then we use the due date based on ultrasound. If not, then we use the due date based on your last menstrual period.

Nicole: And that due date derived from the earliest ultrasound becomes your due date. And it is not changed by subsequent ultrasound examinations. I see a lot of women get confused on this. So you'll have an ultrasound in the early part of pregnancy that gives a estimate for your due date and then say around, you know, 28 or 30 weeks, you have another ultrasound. And on that ultrasound, it is going to say E D D and it's going to give a date. Okay. But that doesn't mean that that is your due date. That is the estimate of the due date based on that ultrasound. But we don't change it from the due date based on the earliest ultrasound that can get really, really confusing. So even if you have another ultrasound, you do not change your due date. You go by the due date that is established at the earliest point in pregnancy.

Nicole: That is the one that is going to be the most accurate. Okay. All right. Now, back in the day we used to use like these mechanical wheels. They're like, they're like these pregnancy wheels that we would use to determine due date, but they are actually not that accurate. And they also are based on a 28 day cycle. So that also leads to the inaccuracy. Now these days, of course we have calculators and, and, and apps and things that can determine due date. And most of these are actually more accurate than those old school pregnancy wheels. So most of us are using electronic techniques, but some of those can be slightly inaccurate as well. So again, don't hang your hat on what you get from one of those apps. You really wanna base it on the earliest ultrasound that you have, and that's even more important if your periods are irregular.

Nicole: All right. So what does it mean when we don't have a good estimate of the due date? That is something called a suboptimally dated pregnancy. So if we have no ultrasound before 22 weeks, then we consider that pregnancy to be suboptimal dated, meaning that the estimate of the due date is not the best. We can't rely on a single number in order to assess how far along the pregnancy is. It can't reliably distinguish between a pregnancy that is, we have the dates wrong, or it's younger than expected, or if growth restriction, you just can't understand when you get an ultrasound beyond 22 weeks and get a single number, you have to redo the ultrasound in order to get a good sense for how the baby's growing. So what we do in that case, the pregnancy is suboptimally dated, meaning there's no ultrasound before 22 weeks.

Nicole: Then we do serial measurements via ultrasound, and we space those out three to four weeks apart. And we don't want to do it any sooner than three weeks because we need some time to see how the baby grows over that time. You'll find this is the case. If there's some concern about your baby's growth, they're not gonna schedule another ultrasound for three weeks because we need those three weeks in order to see how things change over time. Sooner than that, we don't have a good estimate. Okay. So what we do is if you get your first ultrasound after 22 weeks, and actually some folks don't know that they're pregnant until later, especially if you have irregular periods. So if you get that ultrasound after 22 weeks, then you're gonna need another ultrasound in three to four weeks in order to see how the baby grows during that time.

Nicole: Okay. And that is gonna give us a more reliable estimate of the due date. So if the measurements from those two ultrasounds are, um, in sync with each other, then we have more reliable data that, okay, this is the good estimate of the due date. Um, if they're not out, you know, if they're outta sync, then we have to continue to do ultrasounds, to closely monitor the baby's growth. Okay. All right. Now the last thing I'll say about due date is that, um, when you get pregnant from assisted reproduction, then we can calculate the due date a little bit differently when we know the exact conception date or the exact fertilization date, then we can calculate the estimated due date pretty accurately from, from there and how far along you are for sure. Okay. So you can enter one of those calculators, um, the date of egg retrieval, the date of insemination, the date of the embryo transfer, whether it's day three or day five.

Nicole: So with assisted reproduction, we get actually a really accurate estimate cause we know the exact moment that the pregnancy started in those cases and you can calculate the date from there. All right. So next thing I wanna talk about is what happens when you go past your due date because this is a fairly common thing that happens, or at least there's a lot of discussion of it. Okay. So first let me tell you some definitions. So full term is actually defined is 39 weeks and zero days to 40 weeks and six days, we used to define full term after 37 weeks. And we still do in a sense, but really that's like more like early term, 37 to 39 weeks. And full term is 39 weeks, zero days to 40 weeks, six days. All right. Your due date corresponds to exactly 40 completed weeks. So 40 weeks and zero days, 40 weeks and zero days.

Nicole: Okay. And the reason that we have defined full time full term now is 39 weeks zero days is that we don't want to be inducing labor before that for non-medical reasons. So it used to be that people would get induced after 37 weeks, 38 weeks, you know, they wanted to have their baby or, or the, you know, doctor wanted to schedule on a specific day or whatever, and people would get induced um, after 37 weeks. But we have since found that every day up to 39 weeks matters and 39 weeks is like the sweet spot where we know that the vast majority of babies are ready to be born and everything will be good when they're born. And, um, there's a lower risk of complications. So 39 is full term up to 40 weeks and six days. And, and also side note as we are calculating pregnancy, like we never calculate it in, um, months, actually a full term pregnancy of 40 weeks is gonna be over nine months.

Nicole: It's like nine and a half, almost 10 months, cuz a month has four weeks. So the, depending on the timing of the year, it's actually longer than months. So we never talk about pregnancy in months. We always talk about pregnancy in weeks and days. So 40 weeks, one day, 40 weeks, two days, you know, two days it's always weeks and days for pregnancy. That's what we're always gonna go by. We're never gonna talk about pregnancy in months. I okay. Now getting back to the definitions late term, and this is gonna be important in the discussion of going past your due date. So that's why I'm, I'm telling you these. So late term is 41 weeks, zero days to 41 weeks, six days. And then post term is a pregnancy that is greater than or equal to 42 weeks and zero days. Okay. So one more time.

Nicole: Full term is 39 weeks, zero days to 40 weeks, six days. Late term is 41 weeks, zero days to 41 weeks, six days. And post term is greater than or equal to 42 weeks, zero days. And these definitions are important is because the guidelines for how to manage going past your due date, actually focus on late term and post term pregnancies. Okay. So the guidelines that ACOG provides in talking about how to manage going past your due date, actually don't even talk about it until 41 weeks practically. However, a lot of inductions happen between 40 and 41 weeks. All right. So, and actually these days more doctors because of the arrive trial and I've talked about the arrive trial and the podcast episode on induction, um, it's episode 70 of the podcast, uh, the episode on induction, that's drnicolerankins.com/episode70. So the arrive trial found that there is a slightly reduced risk of cesarean birth for first time moms, if you're induced at 39 weeks compared to expected management.

Nicole: So it's like 19 versus 21%. So it's not a huge difference, but slightly decreased risk. And a lot of people have misinterpreted that study actually to mean that you should recommend that everyone is induced at 39 weeks and that's actually not necessary, but don't be surprised if your doctor starts talking about induction at 39 weeks and definitely around your due date. I just see like anecdotally and in communities that I'm in that more and more people are kind of leaning towards recommending, um, induction. It's actually getting to be more and more common. I'm just gonna be honest about that. And it really just depends on the doctor and the practice. I know where I work. We certainly have plenty of folks who are induced, you know, for in the 41st week, for sure. So it really just depends, but don't be, if the conversation comes up now, as far as things that can increase your chances of having what's called a late term or post term pregnancy, the biggest factor is if it happened before, maybe your babies just need to stay in a little bit longer.

Nicole: Also, if it's your first baby that increases your chances are gonna be late term or post post term. And remember 41 weeks is late term. Um, if the baby is a boy that also increases the chances of being late term or post term, and if you're over 35, if you are obese, or if you identify as being white, then you haven't increased chance of having a late term or post term pregnancy. Now, the reason again, that we get concerned when pregnancies go longer is that we know that there's some risk associated with being pregnant longer. One is that the baby may be larger because the baby has had more time to grow. Uh, and having a bigger baby does increase the risk for abnormal labor, abnormal labor progression, cesarean birth, assisted vaginal birth with the vacuum or forceps, um, shoulder dystocia, which is when the shoulder gets stuck underneath the anterior pubic bone on the way out, and then birth injuries, whether those are birth injuries from mom or the baby, and then also postpartum hemorrhage.

Nicole: Okay. So those are risk with the baby being bigger. Now, induction has actually never been shown to help reduce those risk. I know it sounds crazy, but, um, it, it has not been shown to, to decrease those risk, to induce the baby. You would think it would, right? Because if you induce with the baby smaller, you decrease those risk, but it, it really hasn't been shown to make a difference. So we don't recommend induction, although it does kind of commonly happen. And I talk about that in episode 34, the podcast what to do when you have a big baby, that's drnicolerankins.com/episode34. Now some other things that can happen when you are pregnant longer, there's a risk of something called post maturity syndrome. It happens in about 10 to 20% of babies that go past full term and babies can have a long, thin body, long nails.

Nicole: And they're typically small for gestational age, meaning they are smaller than what we expect that they would be. Their skin can be really dry. They don't have a lot of vernix, which is that white moisturizing substance that babies are born with. Sometimes the fluid is meconium stained. Sometimes the skin is like kind of peeling and it's sort of loose and babies with post maturity syndrome are at risk for problems associated with growth restriction, um, like low blood sugar or having, um, low oxygen at birth or meconium aspiration where they breathe in meconium and meconium is, um, when baby has a poop on the inside, they're also at risk for something called a per persistent pulmonary hypertension, which is something that happens in the pulmonary vasculature and then at risk for things like seizures and cerebral palsy. So that doesn't happen very often, but it does happen.

Nicole: Now, the thing that strikes fear into the hearts of all obstetricians and mothers too, of course, is the increased risk of stillbirth that accompanies staying pregnant longer. The reality is that babies born at greater than 41 weeks have one third greater mortality than babies born between 38 to 40 weeks. And the mortality rate at greater than 42 weeks is twice the rate at term, four fold at 43 weeks, and five to seven fold at 44 weeks. I don't think I've ever in my life seen anyone pregnant at 43 or 44 weeks. That just doesn't happen very frequently now. Um, honestly we don't see a lot of folks who are pregnant, um, beyond at 42 weeks. Even now with that being said, although the risk goes up, the absolute risk is actually still very low. So what I mean by that, and this is just a hypothetical example, and I'm gonna go through the numbers in just a minute, but like the risk.

Nicole: So say the risk at, um, 38 to 40 weeks is one then double one out of a hundred, then double that is gonna be two out of a hundred, fourfold for that it's gonna be four out of a hundred. So it's still a low number, but it is increased. So you have to be mindful of that. So it's still not likely to happen. It's just that the risk is greatly increased. Now the largest study to date on the risk of stillbirth and newborn death, it was published in 2019 and they looked at a whole bunch of studies. It was something called a meta-analysis and that's where they take multiple studies and they combine together combine the data together from all of those studies into one big study. And that's called a meta-analysis. All right. And in this particular meta-analysis, it included 13 studies. It looked at 15 million pregnancies and nearly 18,000 stillbirths.

Nicole: And all of these studies were conducted in what are considered high income countries like the United States. So when we looked at that study the risk of stillbirth per 1000 pregnancies, um, and this is gonna be at 37 38 39, 40 41 42 weeks. So I'm gonna go up in those numbers between 37 and 42 weeks. So at 37, 0.11 per 1000, then 0.16 at 38 weeks, 0.42 at 39 weeks, 0.69 at 40 weeks, 1.6, six at 41 weeks and 3.18 at 42 weeks. And that's again per 1000. So you can see that the numbers definitely go up a lot, but the overall risk is still low. And I'm saying that to say, you know, that's information to, to keep handy that, that, you know, so you have a realistic expectation and know what to expect. I can tell you from experience that these numbers are useful, but when you're in the moment and for someone who has a stillbirth, th these numbers like are meaningless because either it happens or it doesn't.

Nicole: So it's hard to, to, in some sense, reconcile those two, because stillbirth is a, a terrible outcome. And you always worry, you know, if the baby was born earlier, could I have prevented it, but know that it is a rare thing that happens, but the risk definitely definitely goes up with each subsequent week of pregnancy. And that risk is even higher for black women. They were 1.5 to two times more likely than white mothers to have a stillbirth at every week of pregnancy in this big meta-analysis study. Now, there are some caveats to that that looked at pregnancies overall, when you look at low risk pregnancy, so not having any problems. And that was defined specifically as a single baby, no abnormalities, no medical conditions in the mother, then the numbers are actually low, lower, I should say. So at 38 weeks, it's 0.12 per 1000.

Nicole: 39 weeks it's 0.14, 40 weeks 0.33, 41 weeks 0.80, and 42 weeks 0.88. Okay. So the risk of stillbirth is low. It definitely goes up, but overall low in low risk pregnancies. Now, some things that may increase your risk of stillbirth. I talked about being a black woman, also being obese. That would be defined as BMI greater than 30. If you are over 35, or if you have diabetes or high blood pressure, those are all things that are gonna increase your risk of stillbirth as does having had a stillbirth in the past. And I do wanna be clear that a risk of having, or going further in pregnancy, aren't just limited to babies. They're increased risk for moms, including an increased risk of infection, increased risk of developing preeclampsia, increased risk of cesarean birth, having a vacuum or forceps birth, and then, uh, postpartum bleeding.

Nicole: All right. Okay. So what are your options for, if you go past your due date, and I wanna be clear that this discussion is really for pregnancies with a single baby, no complications. If you have twins or more, or if your pregnancy has any complications at all, then we always recommend that you should be delivered sooner for your health or for your baby's health. All right. Some conditions where we recommend delivering early, because the risk of stillbirth really starts to go up are if your baby is really small, if you have diabetes, you, if you have high blood pressure. So it really just depends on your pregnancy. All right. So the options are, um, really, it's just a couple options. The first one is induction. I typically, I don't work in the office anymore. I only work in the hospital, but when I was in the office, then I would offer induction at 41 weeks.

Nicole: Okay. About 75% of women will have given birth by 41 weeks. So that's why I recommended 41 weeks. And then also 41 weeks is when the risk of stillbirth really starts to go up. All right. So when you induced by 41 weeks, you're avoiding that increased risk of stillbirth, even if that risk is small, but you're avoiding the increased risk of stillbirth. And there's not a lot of risk necessarily to induction. Yes. There are some risk. And I talk about it in that podcast episode, but you know, you're almost certainly guaranteed to, for it to be successful. Most inductions are successful about 80% of them are. And of course, you're gonna take home a live baby. So I generally say 41 weeks. Okay. And then another weaker reason that I would say 41 weeks is that because after 41 weeks, we recommend closer monitoring with testing twice a week.

Nicole: So, um, and I, when I say 41 weeks, I would say I, I mean, 41 weeks in one, two or three days, like within those first three days afterwards for induction. And then after that, you need to do testing to get monitored, put the baby's heart on the monitor, look at the fluid around the baby to make sure the baby's okay. Um, so you can avoid that if you get induced before 41 weeks, now, if you wanna be induced, then there's, that's totally okay. Honestly, it is not that uncommon for women to just be tired of being pregnant and want to get induced. And there's nothing wrong with that. So as long as you have completed at least 39 weeks, ideally you want your cervix to be favorable so slightly dilated, then doubt or effaced, um, you, before you get induction or before you get induced, rather, but even if your cervix is not favorable, it's still likely to be successful.

Nicole: As long as you are patient with the induction and you give it time, you can certainly have a three or four or five day induction. You just have to be patient with the process. And again, there are risk to induction. I talk about that in episode 70 of the podcast also talk about it in greater detail inside the Birth Preparation Course. Now the second option for what you do is you get past your due date is to wait, you know, and that's just waiting until labor happens on its own. Some people have a strong desire to limit interve interventions. And I totally understand that now because of the risk of stillbirth, most of us will recommend that we start doing testing beginning at 41 weeks. That means you come in twice a week, get that non-stres test where your baby's heart rate is monitored for 20 to 30 minutes.

Nicole: And we take the amount of fluid around the baby to make sure there are no concerns. If there are any concerns, then we do recommend an induction and side note. We are starting to do better about lower intervention options for induction. Like just recently, we had a successful induction with just using nipple stimulation and castor oil. It can work under certain circumstances or a balloon catheter, which isn't a medication. A balloon catheter is really just a balloon that's placed in your cervix is sort of slowly, physically dilates. Um, the cervix that can work very well. And you can avoid medications if you need to. So know that there are some lower intervention options for induction that are available. And please understand. I'm not trying to sway you either way. Like whatever you wanna do is up to you. As long as you have a discussion with your, your provider and know the risk and benefits, pros, and cons of all of the different options, I'm just presenting all of the options to you.

Nicole: Now, I will say a quick note about that fetal surveillance, the putting your baby's, um, heart rate or looking at your baby's heart rate and looking at the fluid. It has not necessarily been shown to reduce outcomes. It has never been studied in like the fanciest or best high quality evidence trial, which is a randomized control trial. And it never will be because of ethical reasons. No one's gonna assign pregnant women to go unmonitored when they go past their due date. But this is the best that we have to monitor a baby's wellbeing. And I will say that very few women will get beyond 42 weeks. That is actually fairly rare, most will deliver by then, um, and go into labor naturally or by induction. And if you do go past 42 weeks, then it actually is pretty strongly recommended that you be induced no later than 42 weeks and six days.

Nicole: Because again, the risk of stillbirth really, really starts to go up. And we just don't have a lot more benefits of staying pregnant at that point. Now a, the American College of Obstetricians and Gynecologists, their position on late term and post term pregnancies and ACOG is what helps set the standard for maternity care in the US. It says induction of labor after 42 weeks and zero days. And by 42 weeks and six days of gestation is recommended given evidence of an increased in perinatal morbidity and mortality induction of labor between 41 weeks, zero days and 42 weeks, zero days of gestation can be considered. So it actually doesn't even recommend induction until after 42 weeks and then consider it after 41 weeks, um, does not recommend the discussion necessarily before then. Okay. So the bottom line is there's no right answer for how things should go.

Nicole: Once you go past your due date, you may be ready to be induced, cuz you're ready to have your baby. Some don't wanna take any chances with still birth. Someone wait as long as possible to go into labor on their own, which I totally understand. That's fine too. And as long as you and your baby are healthy, then you can certainly wait and, and do that. So it's really a personal choice and then just make informed decisions about what you think is best for you, your pregnancy and your family. Okay. So just to recap, your due date is so important. All right. It helps us date all of the things in pregnancy and make decisions and make decisions about how your baby's growing. It is best determined by an ultrasound done in the first trimester. Once your due date is established, it does not change.

Nicole: It is based on the earliest estimate of your due date. Also don't get attached to your due date because it is just that an estimate, most people will not deliver on their due date. They will deliver within a few days around their due date. And if you do go past your due date, the risk of stillbirth does go up, especially after 4 42 weeks. Although the overall risk of stillbirth is low. Now you will be much better prepared for all things, labor and birth with excellent childbirth education. And that is what I offer you inside the Birth Preparation Course, my signature online childbirth education class that gets you calm, confident, and empowered to have, have the most beautiful birth. You can check out all the details of the Birth Preparation Course at drnicolerankins.com/enroll. All right, so there you have it. Do me a couple favors.

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