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    Post Term Pregnancy

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    NishaThakuri
    1. Post-term pregnancy is defined as any pregnancy that has gone beyond 42 weeks from the last menstrual period. The incidence varies from 2-10% depending on the criteria used. 2. Causes of post-term pregnancy are unknown but may include previous post-term birth, irregular periods, advanced maternal age, and other factors. Babies born post-term often show signs of dry skin, nail and hair growth, and discolored skin. 3. Risks of post-term pregnancy include increased cesarean delivery rates, complications during labor for both mother and baby like hypoxia, and higher morbidity and mortality rates for the baby. Care involves monitoring and often inducing labor between 37-42 weeks if

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    Post Term Pregnancy

    Uploaded by

    NishaThakuri
    2K views35 pages
    1. Post-term pregnancy is defined as any pregnancy that has gone beyond 42 weeks from the last menstrual period. The incidence varies from 2-10% depending on the criteria used. 2. Causes of post-term pregnancy are unknown but may include previous post-term birth, irregular periods, advanced maternal age, and other factors. Babies born post-term often show signs of dry skin, nail and hair growth, and discolored skin. 3. Risks of post-term pregnancy include increased cesarean delivery rates, complications during labor for both mother and baby like hypoxia, and higher morbidity and mortality rates for the baby. Care involves monitoring and often inducing labor between 37-42 weeks if

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    1. Post-term pregnancy is defined as any pregnancy that has gone beyond 42 weeks from the last menstrual period. The incidence varies from 2-10% depending on the criteria used. 2. Causes of post-term pregnancy are unknown but may include previous post-term birth, irregular periods, advanced maternal age, and other factors. Babies born post-term often show signs of dry skin, nail and hair growth, and discolored skin. 3. Risks of post-term pregnancy include increased cesarean delivery rates, complications during labor for both mother and baby like hypoxia, and higher morbidity and mortality rates for the baby. Care involves monitoring and often inducing labor between 37-42 weeks if

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    2K views35 pages

    Post Term Pregnancy

    Uploaded by

    NishaThakuri
    1. Post-term pregnancy is defined as any pregnancy that has gone beyond 42 weeks from the last menstrual period. The incidence varies from 2-10% depending on the criteria used. 2. Causes of post-term pregnancy are unknown but may include previous post-term birth, irregular periods, advanced maternal age, and other factors. Babies born post-term often show signs of dry skin, nail and hair growth, and discolored skin. 3. Risks of post-term pregnancy include increased cesarean delivery rates, complications during labor for both mother and baby like hypoxia, and higher morbidity and mortality rates for the baby. Care involves monitoring and often inducing labor between 37-42 weeks if

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 35

    POST TERM PREGNANCY

    Definition
    Literal meaning of prolonged pregnancy or post term
    pregnancy is any pregnancy which has passed beyond
    the expected date of delivery. But for clinical, post
    term pregnancy is as a pregnancy equal to or more
    than 42 completed weeks from the first day of the last
    menstrual period.

    Incidence
    The incidence is varies from 2-10% because
    different criteria in definition. According to
    retrospective study of delivery beyond 290 days
    the incidence is low as 2 %. Based on delivery
    beyond 42 weeks, the incidence come 10%. When
    an early ultrasound scan is used the incidence is
    reduced from 10% to 3% . (Hovi et al 2006)

    Causes

    The causes of post term pregnancy is unknown.


    1. Previous post mature birth.
    2. Irregular menstrual cycle.
    3. Primi gravida
    4. Elderly pregnancy
    5. High socioeconomic status
    6. Sendentary life style
    7. Anencephaly without polyhydramnious

    9. Male fetus (placental sulphatase deficiency)


    10.Fetal adrenal hypoplasia
    Symptoms of post mature baby:
    Different babies will show different symptoms of
    postmaturity. Some postmature babies will show no or little
    sign of postmaturity. The most common symptoms are:
    -. Dry skin
    -. Overgrowth nails
    -. Creases on the babys palms and soles of their feet.
    -. Minimal fat
    -. A lot hair on their head
    -. A brown, green or yellow discoloration of their skin

    Diagnosis
    1.Last menstrual period (LMP) : if mother is sure about
    her date of menstrual cycle, it is fairly reliable diagnostic
    aid in calculation of EDD. In case of mistakem pregnancy
    can be occur any time like lactational amenorrhoea period
    or withdrawl of pill which make confusion.
    2. From date of quickening: normal quickening occurs
    between 18-20 weeks pregnancy.
    3. Fundal height

    4. Suspected clinical findings: weight loss, girth of the


    abdomen gradually diminishes because of diminishing
    liquor volume, history of false pain, fundal height, fetal part
    can be palpable on abdominal palpation, cervical ripening
    on internal examination.
    5. Investigations:
    - Ultrasound
    - X-ray abdomen
    -Amniocentesis:- biochemical and cytological
    may help in assessment of maturity.

    paramiters

    Risk or Complications of Post- term Pregnancy


    Maternal effects
    i.

    Incidence cesarean section rate is double.

    ii. Increased incidence of induction of labor, instrumental


    delivery
    iii. Risk of birth canal trauma and postpartum hemorrhage
    iv. Prolonged labor or CPD due to large and mature skull
    v.

    Increased anxiety and fear

    Fetal effects
    i.

    Chances of fetal hypoxia due to placental insufficiency during


    pregnancy.

    ii. IUGR 20%


    iii. Larger than date of prenancy
    iv. Fetal death may occur
    v.

    Decreased liquor volume

    vi. Increased risk of asphyxia and intracranial damage during labor


    vii. Muconium aspiration syndrome and atelectasis due to
    intrauterine anoxia and inhalation of meconium
    viii. Hypoglycemia and polycythemia in IUGR post term babies
    ix. Increased perinatal and neonatal mortality and morbidity due to
    low APGAR score.

    Management of Post-term Pregnancy


    Management of prolonged pregnancy must include an
    accurate dating

    of the pregnancy to determine the

    pregnancy is prolonged for that individual. The management


    is depend on complicated or uncomplicated pregnancy.
    1. Mother should admit in hospital and allowed to continue till
    spontaneous onset of labor.
    2. Periodic assessment of fetal wellbeing is to be done through
    CTG to monitor fetal heart rate and AFI index so that early
    evidence of fetal compromise can be deal.

    3. Exclude all possible complication such as diabetes, CPD,


    toxemia, Rh negative blood.
    4. Induction of labor if spontaneous labor is not onset with 1014 days after EDD.
    5. complicated post-term pregnancy like contracted pelvis, post
    ceasarean pregnancy, malpresentation, elderly primigravida.
    6. Association of complication like pre-eclampsia, history of
    APH, diabetes, Rh-negative should not allowed to past the
    expedted date of delivery

    Induction of labor
    The induction of labor is an intervention to initiate the
    process of labor by artificial means in pregnancies from 24
    weeks (period of viability) of gestation which aims at a
    vaginal delivery. The decision to induce labour should only
    be made when it is clear that a vaginal birth is the most
    appropriate mode of delivery in this pregnancy,
    Incidence
    The incidence of induced labour varies in different hospital
    but generally showing a rising trend about 10-15% in india

    Indications of induction of labour


    Maternal
    Prolonged pregnancy
    Hypertension including pre-clampsia to expedite the
    delivery as severity of symptoms.
    Pre-labour rupture of membranes (more than 24 hour)
    APH
    Elderly primigravidae
    Minor degree of placenta praevia
    Chronic renal disease
    Abruptio placenta

    Fetal
    Intrauterine growth restriction
    Macrosomia
    Fetal death
    Previous unexplained IUD
    Gross congenital anomalies of the fetus
    Post maturity
    Chronic placental insufficiency
    Rh-isoimmunization
    Unstable lie
    Multiple pregnancy

    Contraindications

    Contracted pelvic
    Malpresentation(transverse or oblique)
    Known CPD
    Prematurity
    Cardiac disease
    Elderly primigravida associated with complication
    Pelvic tumor
    Previous caesarean section
    Carcinoma of cervix
    Active genital herpes infection
    Umbical cord prolapsed
    Severe actual fetal compromise
    Placenta praevia

    Methods of induction
    Prior to any method used to induce labour, it is extrem ely
    important for the midwife to carry out an abdominal
    examination confirming the lie, presentation, descent of
    presenting part and fetal wellbeing. Before starting the
    induction condition of the cervix should assess, cervical
    exam is to be performed.The bishops sore should 6 or
    more than 6 is favourable for induction, below 5 is
    unfavourable for induction.

    The common methods used for induction of


    labor are:
    1. Medical induction
    2. Surgical induction
    3. Combined

    Medical Induction
    In medical induction the drugs are used for labour
    induction.
    Indications:
    i) Exclusive
    - Intrauterine death (IUFD)
    - Premature rupture of the membrane (PROM)
    ii) In case of failure of surgical induction as an
    alternative to caesarean section.

    Drugs:

    Oxytocin
    Prostaglandin
    Oxytocin
    Oxytocin is a hormone released from the posterior
    pituitary gland. It acts at cell level on smooth muscle and
    is released in a pulsed manner in response to stimulation.
    Receptor to oxytocin are found in myometrium and
    increase in number at the terms and throught labour.

    Principles of Induction of Labour


    1. The oxytocin should be started at low dose but
    increases quickly where there is no response because
    its erractic response.
    2. When the optimal responses are achieved (severe
    uterine contraction), the administration of the
    particular concentration in mu/min is to be
    continued. This is called oxytocin titration
    technique.
    3. The objective of oxytocin administration is not only
    to initiate effective contraction but also maintain
    normal pattern of uterine activity till delivery and at
    least 30-40 minutes beyond that.

    Regime of oxytocin
    Multigravidae uterus or the uterus which is already
    contracting is much more sensitive to oxytocin. In this
    respect , the primigravidae uterus is less sensitive.The
    patient should preferably lie on one side or in semifowlers position to minimize vanacaval compression.
    1. First regimine:- Mix 2.5 unit syntocin in 500 ml of
    destrose or ringers lactate and start at 10 drops/minute
    to evaluate the sensitivity of the patient to drugs.
    Theafter increase the drop rate gradually with 10 drops
    in every 30 minutes up to 60 drops per minute depending
    on the response that is frequency and strength of uterine
    contraction.

    If good contraction pattern has not obtained with the infusion rate at
    60 drops/min, increase oxytocin concentration to 5 units in 500ml
    dextrose or normal saline or ringer lactate.
    Second regime:
    5 units of oxytocin added to 500 ml dextrose and give approximated
    0,5 mu in one drop of infusion. The starting dose low as 30 drops
    per minute (5 mu), increase the 10 drops at 30 minute intervals and
    maximum of 60 drops per minute (30mu/min) according strength
    and frequency of uterine contraction. If good contraction pattern
    still has not been establishe using higher concentration of oxytocin
    in multigravida and with previous C/S scare, induction has failed
    deliver by caesarean section.

    Observation during oxytocin infusion

    Moniter the mothers pulse, blood pressure and contractions and


    check fetal heart rate.
    Review for inductions, be sure induction is indicated as failed
    induction is usually followed by caesarean section.
    Ensure that mother is on her left side.
    Record the rate of infusion, duration and frequency of contration
    and fetal heart rate on a partograph every 30 minutes.
    Moniter FHS every 30 minutes, always immediately after
    contraction. If FHS is less than 100 bpm, stop the infusion and
    manage for fetal distress.

    Mother receiving oxytocin should never be left alone.


    Increase the infusion rate 10 drops per minute every 30 until
    good contraction pattern is established ( 3contraction in 10
    seconds and each lasting 40 seconds).
    Maintain this rate till delivery is completed.
    If hyperstimulation occurs ( 4 contraction in 10 minute and
    each contraction lasts longer than 60 seconds), stop the
    infusion and relax the uterus using tocolytics such as:

    turbutaline 250 mcg IV slowly over 5 minutes

    Or salbutamole 10 mg in 1 liter IV fluids at 10 drops per minute.

    Do not use oxytocin 10 units in 500 ml (20mIU/min)


    in multigravida and women with previous C/S.
    Infuse oxytocin at higher concentration (10 unitsin
    500 ml) in primigravida.
    If good contraction are not established at the
    maximum dose, deliver by caesarean section.

    PROSTAGLANDIN
    Prostaglandins are highly effective in ripening of cervix during
    induction of labour. Bishops score should be assessed before using
    prostaglandin for the cervix is fabourable or not.
    Indications:
    Medical termination of pregnancy
    Termination of abnormal pregnancy
    Missed abortion
    IUFD
    Molar pregnancy
    Major fetal abnormality like anencephaly

    Procedure

    Moniter the womans pulse, blood pressure and contraction


    and check the fetal heart rate.
    Record findings on a partograph.
    Review for inductions
    The prostaglandin is placed high in the posterior fornix of
    the vagina and may be repeated after six hours if required.
    Moniter uterine contraction and fetal heart rate of all
    women undergoing induction of labour with prostaglandins.

    Discontinue use of prostaglandins and begin oxytocin infusion


    if:
    Membrane rupture
    Cervical ripening has been achieved
    Good labour has been established
    Or 12 hours have passed.
    Misoprostol
    Use misoprostol to ripen cervix only in highly selected
    situations such as: severe pre-eclampsia when the cervix is
    unfavourable and safe C/S is not immediately available or the
    baby is too premature to survive.

    Fetal death is utero if the woman has not gone into spontaneous
    labour after four week and platelets are decreasing.
    Place misoprostol 25mcg in the posterior fornix of the vagina.
    Repeat after six hours if required.
    If there is no response after two doses 0f 25cmg, increase to 50
    mcg every six hours.
    Do not use more than 50mcg at a time and do not exceed foru
    doses (200mcg)
    Do not use oxytocin within 8 hours of using misoprostol.
    Moniter uterine contractions and fetal heart rate.

    Surgical induction
    The initiation of labour is attempt by surgical method and is almost
    exclusively done by rupture of the membranes.
    Indication:
    1)APH
    2) Chronic polyhydramnious
    3) Severe pre-eclampsia and eclampsia
    4) As combined with medical induction
    Contraindication:
    i. IUFD
    ii. Moderate to severe CPD
    iii. Abnormal lie

    Combined Method
    Refer midwifery B book

    Procedure
    Review for indication
    In areas where HIV and/or hepatitis are highly prevalant, it should leave
    the membranes intact for as long as possible to reduce perinatal
    transmission of HIV.
    Listen and note the fetal heart rate.
    Ask the woman to lie on her back with her legs bent, feet together and
    knees apart.
    Wearing high- level disinfected or sterile gloves, use one hand to
    examine the cervix and note the consistency, position, effacement and
    dilatation.
    Use the other hand to insert an amniotic hook or a kocher clamp into the
    vagina.
    Guide the clamp or hook towards the membranes along the fingers in
    the vagina

    Place two fingers against the membrabes and gently


    rupture the membrane with the instrument in other
    hand. Allow the amniotic fluid to drain slowly
    around the fingers.
    Note the color of the fluid(clear, greenish, bloody),
    If thick meconium is present, suspect fetal distress.
    After ARM listen FHS during and after a
    contraction. If FHS is abnormal (less than 100or

    If membrane have been ruptured for 18 hours give


    prophylactic antibiotics to reduce group B streptococcus
    infection in neonate. Penicillin G 2 million units IV or
    Ampicilin 2 g IV every 6 hours until delivery. If there is
    no sign of infection after delivery discontinue antibiotics.
    If good labour is not established one hour after ARM
    begin oxytocin infusion.
    If labour is induced because of severe maternal disease,
    begin oxytocin infusion at the same time as ARM.

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