American Journal of Obstetrics and Gynecology (2005) 192, 185e90

www.ajog.org

Neonatal complications of term pregnancy: Rates by

gestational age increase in a continuous,
not threshold, fashion
Aaron B. Caughey, MD, MPP, MPHa,b A. Eugene Washington, MD, MSc,a
Russell K. Laros, Jr, MDa

Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, Calif, a
and Division of Health Services and Policy Analysis, University of California, Berkeley, Calif b

Received for publication April 25, 2004; revised June 11, 2004; accepted June 21, 2004

KEY WORDS
Perinatal morbidity
Postterm pregnancy
Postdates pregnancy
Objective: The purpose of this study was to determine whether, when, and how rates of short-
term neonatal complications increase beyond 37 weeks of gestation.
Study design: A retrospective cohort study was conducted of all low-risk, term, cephalic, and
singleton births that were delivered at the University of California, San Francisco, between 1976
and 2001. Primary outcomes included neonatal umbilical artery pH, umbilical artery base excess,
the presence of meconium, macrosomia, 5-minute Apgar scores, and admission to the intensive
care nursery. Multivariate analyses were performed that controlled for maternal ethnicity, weight,
age, socioeconomic status, and obstetric history.
Results: Among the 32,679 women who were delivered at R37 completed weeks of gestation, the
rates of umbilical artery pH !7.0, umbilical artery base excess less than
12 increased beyond 40
weeks of gestation, and the presence of meconium increased beyond 39 weeks of gestation (chi-
squared test; P ! .001). These outcomes continued to increase in each subsequent week, and these
findings persisted when they were controlled for potential confounders in multivariate models.
Conclusion: We found that the rates of immediate neonatal morbidity increase with increasing
gestational age. Accurate determination of these rates is important in the determination of
gestational age at which the risk of continuing the pregnancy outweighs the risk of induction of
labor.
Ó 2005 Elsevier Inc. All rights reserved.

Clifford et al1 noted that, although pregnancies which
persisted beyond 43 weeks of gestation occurred !5%
of the time, they accounted for 30% of the perinatal
Supported in part by the National Institute of Child Health and
Human Development, grant # HD01262 (A.B.C.).
Reprints not available from the authors.
deaths. Thus, since the advent of antenatal fetal
surveillance, one intent has been the prevention of fetal
death among postterm pregnancies. In the 1970s and
1980s, this was defined commonly as patients beyond 42
completed weeks of gestation, or 294 days,2 which
complicates O10% of pregnancies.3 In addition to an
increased perinatal mortality rate,4-8 numerous studies
have associated postterm pregnancies with increased

0002-9378/$ - see front matter Ó 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajog.2004.06.068
186
rates of neonatal morbidity, which includes meconium
and meconium aspiration syndrome,4,9,10 oligohydram-
nios,11 macrosomia,4,10,12 and fetal birth injury.13 How-
ever, most of these studies that examine gestational age
do so by establishing thresholds such as 41 or 42 weeks
of gestation and comparing rates of complications
beyond this threshold to those in patients who are
delivered below the threshold.
This type of comparison, which may have been used
in earlier studies to increase statistical power, can lead to
several false conclusions. First, if the rate of complica-
tions just before the threshold is similar to that just
beyond the threshold, but the rate goes down much
earlier, on average it may seem that the rate increases
beyond the threshold. Conversely, if the complications
beyond the threshold are at first no different but then
increase dramatically, it might seem that, on average,
patients above that threshold are at higher risk for the
complications. Clinically, patients and their physicians
wish to know what the risk is of continuing a pregnancy
beyond any given point over the next time interval and,
in particular, whether the risk of a given complication
increases compared with the previous time interval.
Thus, the types of analyses that analyze risks by
thresholds are of much less use clinically than an
analysis that considers the rates of complications by
week of gestation. Studies that have examined the risk of
fetal death by the week of gestational age demonstrate
that rates increase in a steadily rising fashion, as
opposed to a sudden jump beyond a given thresh-
old.14,15 If this complication of pregnancy increases,
not as a discrete risk beyond some particular gestational
age, but instead continuously with increasing gestational
age, other neonatal complications that are associated
with postterm pregnancies may do the same.
Although the rates of low Apgar scores and intensive
care nursery (ICN) admissions have been examined and
shown to increase by week of gestation,10 other short-
term neonatal measures of long-term morbidity have
not. In one study of umbilical artery pH !7.0 and 5-
minute Apgar scores !4, no difference between 40, 41,
and 42 weeks of gestation was shown, although the
authors did find an increase in neonatal sepsis.16
Although 5-minute Apgar scores both !4 or 7 have
been associated with poor long-term outcomes,17 other
authors suggest that newborn umbilical artery acid-base
status is a more predictive short-term measure of long-
term neonatal outcome.18 Umbilical artery base excess
less than
12 has been cited as a particularly useful
threshold.19 A recent study suggested that a pH !7.0
had relatively good sensitivity (74%) for the identifica-
tion of neonates who would undergo early neonatal
seizures as the result of hypoxic ischemic encephalopa-
thy.20
Given this background, and a particular intent to
examine neonatal complications by week of gestation
Caughey, Washington, and Laros
rather than simple dichotomous comparisons, we sought
to explore neonatal complications of pregnancy O37
weeks of gestation in an otherwise low-risk cohort of
patients. Specifically, we were interested in determining
at what gestational age the rates of neonatal complica-
tions increase over the previous week of gestation.
Further, we were interested in whether these complica-
tions continued to increase beyond the initial rise and in
what fashion.
Methods
We designed a retrospective cohort study of all single-
ton, cephalic, low-risk neonates who were delivered at
O37 weeks of gestation from January 1, 1976, to
December 1, 2001, at the Moffitt-Long Hospital associ-
ated with the University of California, San Francisco.
Exclusion criteria included delivery !37 weeks of
gestation and pregnancies that were complicated by
diabetes mellitus, preeclampsia, chronic hypertension,
collagen vascular disease, fetal anomalies, nonecephalic
presentation, placenta previa, previous cesarean deliv-
ery, and multiple gestation. At our institution, umbilical
artery and vein blood gases are obtained on every
neonate. Information on the following outcomes were
collected: umbilical artery pH, umbilical artery base
excess, presence of meconium, macrosomia (O4500 g),
admission to the ICN, 5-minute Apgar scores, birth
trauma (including skull fracture and brachial plexus
injuries), neonatal seizures, intracranial hemorrhage,
neonatal sepsis, meconium aspiration syndrome, and
respiratory distress syndrome. The following variables
were examined as confounders: maternal age, ethnicity,
education, length of labor, mode of delivery, year of
delivery, parity, anesthesia, birth weight, and labor
management (induction of labor, augmentation of labor
through artificial rupture of membranes, and augmen-
tation of labor with oxytocin). This study was approved
by the investigational review board at the University of
California, San Francisco.
The data were then compiled and analyzed with
STATA software (version 7; Stata Corporation, College
Station, Tex). Because the primary predictor of interest
was gestational age by week, the dependent variables of
interest were compared in a bivariate fashion with
gestational age from R37 weeks. Because the outcomes
of interest were neonatal rather than fetal, the de-
nominator used to calculate rates was all pregnancies
that were delivered during the particular week of
gestation. Because the rates of many of the neonatal
complications were low, a summary variable called
severe complications was created that included birth
trauma (including skull fracture and brachial plexus
injuries), neonatal seizures, intracranial hemorrhage,
neonatal sepsis, meconium aspiration syndrome, and
Caughey, Washington, and Laros 187

respiratory distress syndrome. Comparisons of propor-

Table I Demographics and descriptive obstetric outcomes
tions were made with the use of the c2 test; means were
compared with the use of the Student t test. For those Percentage of low-risk
Variable patients
variables of interest and those variables that exhibited
an increasing bivariate trend with increasing gestational Maternal age R35 y 14.8
age, a multivariate logistic regression was performed College graduate 51.5
that included potential confounders and used dummy Medicaid insurance 39.4
Ethnicity
variables for each week of gestation in the model as
Black 11.8
independent variables. Cross product terms to examine Asian 26.3
interaction between predictor variables were created. Hispanic 9.4
Their contribution to the model was tested with the White 39.0
maximum likelihood ratio test and were kept only in the Other (Native American, 13.5
model if they were statistically significant. Statistical unknown)
significance was defined as a probability value of !.05. Nulliparous 52.1
Birth weight R4000 g 12.6
Cesarean delivery 17.6
Operative vaginal delivery 15.0
Results
During the study period, there were 36,947 women who
were delivered at O37 completed weeks of gestation. We
Table II Abnormal neonatal acid-base status or 5-minute
excluded 4268 patients (11.6%) who fell into 1 of the
Apgar scores
high-risk groups (preeclampsia, diabetes mellitus, colla-
gen vascular disease, previous cesarean delivery, pla- Gestational N UA pH UA base excess 5-min Apgar
centa previa), were non-cephalic, or had a multiple age (wk) !7.0 (%) less than
12 (%) !7 (%)
gestation. This left 32,679 low-risk patients for analysis. 37 2053 0.85 0.92 4.22
These patients were ethnically diverse and relatively 38 4489 0.75 0.72 2.15*
well-educated, as indicated by the 51.5% who had 39 7626 0.78 1.02 1.83
completed 4 years of college (Table I). When short-term 40 9808 0.50 0.89 1.78
41 5717 1.09* 1.72y 2.68*
neonatal outcomes were examined by week of gestation,
42 2312 1.43* 2.03z 3.82*
there was a statistically significant increase in the rates 43 674 1.33 2.68z 3.35
of umbilical artery pH !7.0 and base excess less than
Statistical significance as compared with the rate of complication in

12 (Table II) in patients who were delivered at 41
the previous week of gestation.
weeks of gestation, compared with those patients who * P ! .01, c2 test.
were delivered at 40 weeks of gestation. This held true y
P ! .001, c2 test.
z
for 5-minute Apgar scores !7 and ICN admissions P ! .05, c2 test.
(Table III). When rates of meconium-stained fluid and
macrosomia were examined, these rates began to in-
crease to O38 weeks of gestation and continued in- beyond 41 weeks of gestation, the rates of umbilical
creasing through 42 weeks, when compared with the artery pH !7.0, and base excess less than
12 were
rates in the previous week (Table III). When we increased, as were the rate of 5-minute Apgar scores !7.
examined the rates of most of the more severe neonatal These rates continued to increase beyond 42 weeks of
complications, as we suspected, the actual numbers were gestation. After being controlled for confounders, both
too low to have adequate power to be examined by week the rates of meconium aspiration syndrome and the
of gestation. However, when we examined the summary overall rates of severe neonatal complications were
variable, severe complications, we did find an increasing increased to O40 weeks of gestation.
trend by week of gestation at O40 weeks of gestation To further examine how increasing a week of
(Table III). gestation affected neonatal acid-base status, we first
We next examined gestational age as a predictor for looked at the mean umbilical artery pH and base excess
these short-term neonatal outcomes using multivariate values by gestational age. We found that these values
logistic regression to control for maternal age, ethnicity, both tended to decrease with increasing gestational age
education, parity, mode of delivery, birth weight, length (Figures 1 and 2). Multivariate linear regression was
of labor, and induction. Beyond 40 weeks, gestational then used to examine umbilical artery pH and base
age was found to predict an increased risk for meco- excess. Considering just those deliveries 39 weeks and
nium-stained fluid and macrosomia (Table IV), when beyond, by increasing one week of gestation, the mean
compared with pregnancies that were delivered at 39 pH is lowered by 1% or approximately .06 (P ! .001)
weeks of gestation. Similar to the bivariate comparisons, and the base excess is lowered by 31% (P ! .001). These
188 Caughey, Washington, and Laros

Table III Neonatal complication rates by week of gestation

Gestational age (wk) N Meconium (%) Macrosomia (%) ICN admissions (%) Severe complications (%)*
37 2053 11.0 0.58 8.5 3.56
38 4489 13.8y 0.88y 4.5z 1.95x
39 7626 18.3z 1.15y 3.1y 1.84
40 9808 25.8z 2.22x 2.6 2.31y
41 5717 31.9z 3.58z 3.4x 3.14x
42 2312 35.4y 5.89z 4.7x 3.82x
43 674 37.2 8.57y 4.9 4.55y
Statistical significance as compared with the rate of complication in the previous week of gestation.
* Included birth trauma (including skull fracture and brachial plexus injuries), neonatal seizures, intracranial hemorrhage, neonatal sepsis, meconium
aspiration syndrome, and respiratory distress syndrome.
y
P ! .05, c2 test.
x
P ! .01, c2 test.
z
P ! .001, c2 test.

Table IV Association of gestational age with perinatal complications in multivariate model*

Gestational age odds ratio (95% CI)
Outcome 40 weeks 41 weeks 42 weeks
5-minute Apgar 0.97 (0.77, 1.22) 1.36 (1.07, 1.74) 1.71 (1.27, 2.30)
score, !7
UA pH !7.0 0.75 (0.42, 1.33) 1.65 (1.01, 2.77) 2.31 (1.25, 4.27)
UA BE !
12 0.89 (0.65, 1.21) 1.59 (1.17, 2.16) 2.14 (1.49, 3.08)
Meconium 1.56 (1.44, 1.69) 2.04 (1.87, 2.22) 2.39 (2.13, 2.68)
Macrosomia 2.32 (1.71, 3.13) 4.26 (3.16, 7.14) 5.62 (4.02, 7.85)
ICN admissions 0.91 (0.74, 1.11) 0.99 (0.79, 1.24) 1.46 (1.13, 1.91)
Meconium aspiration 2.18 (1.26, 3.78) 3.35 (1.93, 5.84) 4.09 (2.07, 8.08)
Severe complications 1.47 (1.09, 1.98) 2.04 (1.50, 2.78) 2.37 (1.63, 3.49)
Severe complications included birth trauma (including skull fracture and brachial plexus injuries), neonatal seizures, intracranial hemorrhage, neonatal
sepsis, meconium aspiration syndrome, and respiratory distress syndrome.
* Each outcome was examined in a separate multivariate analysis and compared with pregnancies that were delivered at 39 weeks of gestation and
was controlled for maternal demographics, length of labor, induction, mode of delivery, and birth weight (except macrosomia). The odds ratios (95% CIs)
that do not cross unity are bolded.

findings were consistent with the trends in the mean pH
and mean base excess values, which both decreased at
O39 weeks of gestation (P ! .01 for both, Student
t test). Cross-product terms were not found to be
significant in any of the multivariate models and were
not used in the final models.
Comment
When we examined neonatal acid-base status, we found
that both the umbilical artery pH and base excess
decreased in a continuous fashion after 39 weeks of
gestation. Further, when we examined the rates of term
neonates who had umbilical artery pH !7.0 and base
excess less than
12, we found that the rates increased
beyond 41 weeks of gestation. Other complications
(such as rates of meconium and macrosomia) increased
in pregnancies beyond 38 weeks of gestation. These
findings are markers for other neonatal morbidity and
deaths and, in particular, are associated with meconium
aspiration syndrome21 and birth injury, respectively.22
Further, we found that that the rate of meconium
aspiration syndrome did increase beyond 40 weeks of
gestation as did the overall rate of severe neonatal
complications.
Our rates and trends by gestational age of umbilical
artery pH !7.0 differ from those reported by the only
other study in the literature that examined neonatal
umbilical artery pH by the week of gestation.16 How-
ever, although the other analysis was limited to exam-
ining pH !7.0, we also examined base excess less than

12, mean pH, and mean base excess and found the
same trends in all 4 measures. Interestingly, although we
found that the mean pH and base excess decrease at
O39 weeks of gestation, this did not lead to meaningful
increases in the rates of neonatal acidemia until 41
weeks of gestation was reached.
When managing patients who have progressed be-
yond their estimated date of confinement, our goal as
Caughey, Washington, and Laros
Figure 1 Mean umbilical artery pH (uapH) by week of
gestation. All differences between weeks are statistically
significant, except 37 to 38 weeks of gestation.
clinicians is to minimize both maternal and neonatal
complications. Maternal complications of pregnancy
that include cesarean delivery,10,16 operative vaginal
delivery,10,16 3rd- and 4th-degree perineal lacerations,10
and preeclampsia23 have all been shown to increase with
increasing gestational age. Further, the rate of cesarean
delivery has been shown to decrease when patients
undergo routine induction at 41 weeks of gestation, as
compared with expectant management with antenatal
testing.24 In our analysis, we found that a number of
short-term neonatal complications also increased with
increasing gestational age. Certainly, all of our measures
increased beyond 41 weeks, as compared with 40 weeks
of gestation.
If antenatal testing is begun at an earlier gestational
age, it is reasonable to assume that more patients with
a need for delivery will be identified. The suspicion has
been that the induction of labor increases the rate of
cesarean delivery,25 although most studies that support
this finding have not been randomized, controlled trials.
Conversely, when Hannah et al24 randomly assigned
patients to the induction of labor at 41 weeks of
gestation, they found a decrease in the rate of cesarean
deliveries. In a recent meta-analysis of the 16 random-
ized, controlled trials in the literature, the overall effect
that was found was also a decrease in the rate of
cesarean delivery.26 Further, the efficacy and risk profile
of the existing and new methods for labor induction
have continued to improve over time. Thus, we will need
to reassess the risks and the benefits from expectant
management versus labor induction in these patients
with only the most current data. If labor induction
methods improve and the risks of increasing gestational
age begin earlier than previously suspected, there may be
an indication to intervene at an earlier gestational age.
Given our data, it may be found that the balance of risks
and benefits for intervention in low-risk pregnancies
should be earlier than the current management. The
most recent recommendations by the American College
of Obstetricians and Gynecologists have defined that
189
Figure 2 Mean umbilical artery base excess (uaBE) by week
of gestation. All differences between weeks are statistically
significant, except 37 to 38 and 38 to 39 weeks of gestation.
threshold to be at 42 weeks of gestation.3 However, on
the basis of these data and existing literature, we would
suggest that this threshold should be reconsidered.
Our study is not without limitations. A retrospective
study can be compromised by having multiple con-
founding variables. In our analysis, we controlled for
these confounders in two ways. First, we limited our
analysis to low-risk patients. Second, we used multivar-
iate models to control for maternal demographics,
obstetric history, and labor management and outcomes.
Although we did not have information on all confound-
ers, we attempted to control for those that we consid-
ered important to these outcomes. Further, we did not
have all the information on our patients’ socioeconomic
status, in particular income, and used education as
a proxy. Another possible limitation pertains to the
generalizability of our study population to that of all
pregnant women. The patients in our study were treated
at an academic center in California where the use of
elective induction of labor rarely is performed. Other
than this, our patient population represented a wide
spectrum of ethnicities, age, and educational status.
Furthermore, when we controlled for the various
maternal characteristics, our findings were robust.
The determination at what gestational age pregnancy
complications are increased is important in the
determination of both when pregnancies should be
screened for complications with antenatal fetal testing
and when a delivery plan should be initiated. Our
findings suggest that some neonatal complications in-
crease at beyond 39 weeks of gestation. Whether
beginning antenatal fetal testing earlier to identify some
of these potential complications will lead to better
outcomes must be examined in large prospective trials.
Further, the effect of false-positive rates in such screen-
ing protocols should be considered. At the very least,
our findings suggest that the optimal gestational age to
initiate delivery requires further investigation.
190
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