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  2. 2. INTRODUCTION • The normal length of pregnancy is from 37 weeks to 42 weeks • Prolonged pregnancy is also referred to as post term, post maturity and postdates pregnancy and is said to be the one that exceeds 42 weeks of gestation
  3. 3. Cont… • Prolonged pregnancy and post term are used synonymously and relate to the duration of pregnancy and not a maternal condition ( Fraser et.al, 2006). • The actual incidence is relatively small as it occurs in approximately 2% to 12% of all pregnancies (Paul et al, 2006). • The most frequent cause of post term pregnancy is inaccurate dating
  4. 4. Cont… • Prolonged pregnancy is the most common reason for induction of labour. • About 5% of these neonates show characteristics of post mature syndrome (Murray and Mickinney, 2006) . • The post newborn is at high risk for morbidity and has a mortality rate two to three times greater than that of term infants. However, death is uncommon today because of the early detection and intervention (Gloria, 1999).
  5. 5. GENERAL OBJECTIVE • At the end of the lecture, students should be able to have an understanding and knowledge on management of a woman with prolonged pregnancy. SPECIFIC OBJECTIVES • Define prolonged pregnancy and post maturity. • State the causes of prolonged pregnancy.
  6. 6. Cont…. • Outline the risk factors of prolonged pregnancy • Explain the diagnosis of prolonged pregnancy. • State the risks and clinical implications of post term pregnancy. • Discuss the management of prolonged pregnancy. • Explain the complications of prolonged pregnancy.
  7. 7. Cont… • Describe the characteristics of a Post Mature Neonate. • Explain the problems associated with a Post Mature Neonate • Discuss the management of a Post Mature Neonate
  8. 8. DEFINITIONS • Prolonged pregnancy; Defined as a pregnancy that exceeds 42 weeks gestation or 294 days past the first day of the mothers last normal menstrual period (Marcia et al, 2007). • Post term; Any newborn born after 42 weeks of gestation (Joel et al, 2007).
  9. 9. ABBREVIATIONS • Intra uterine growth retardation (IUGR); • Expected date of delivery (EDD); • Last monthly period (LMP)
  10. 10. CAUSES • The cause of prolonged pregnancy is idiopathic. RISK FACTORS • Miscalculation or inaccurate last menstrual period. • Lack of stimulation factors such as oxytocin and prostaglandins e.g. in women who take high doses of aspirin or like compounds, which are known to inhibit the synthesis of prostaglandins.
  11. 11. Cont…. • Lack of stimulus of the cervix and lower segment by presenting part that is in malpresentation, occipital posterior position or short umbilical cord. • Prime gravidae have a longer mean duration of pregnancy averaging 288 days because the first pregnancy tends to last longer than subsequent pregnancies. • High parity ( five or more pregnancies)_ the recurrence risk of post term birth increases with parity.
  12. 12. Cont… • Previous post term pregnancy increases the risk of recurrence in subsequent pregnancy • Male gender of the fetus • Genetic factors may also play a role as studies show certain genes predispose to prolonged pregnancy. • Advanced maternal age is a strong risk factor (over 35 years)
  13. 13. DIAGNOSIS • The accurate diagnosis of postdates pregnancy can be made on by proper dating. • The estimated date of delivery is most accurately determined early in pregnancy. However, the following aid in diagnosis. History taking • Establish the first day of the last normal menstrual period. Then calculate the expected date of delivery. For the EDD to be accurate:
  14. 14. Cont…. • The woman should be sure of her LMP • The period must have been of normal length and regular. • Not having been on oral contraceptives pill. • Quickening; maternal perception of first fetal movements at about 16-20 weeks.
  15. 15. Abdominal examination • On abdominal inspection the pregnancy appears bigger than the gestational age. • Abdominal palpation for height of fundus which will be more than 40 weeks. Ultra sound scanning • In patients without reliable clinical data, ultrasound is beneficial. However, ultrasonography is most accurate in early gestation (before 12weeks).
  16. 16. Cont…. • After 12weeks,the crown-rump length becomes less accurate in determining gestational age because the fetus begins to curve. • Ultra sound can also show placental calcification and the amount of amniotic fluid at term which is reduced in postterm.
  17. 17. RISKS AND CLINICAL IMPLICATIONS OF POST-TERM PREGNANCY. FETAL RISKS • AT the end of pregnancy, the placenta which supplies the fetus with oxygen, nutrients and removal of wastes begins to fail to function properly due to aging or infarction. • Therefore, the baby’s health may be at risk of asphyxia, respiratory distress syndrome and meconium aspiration. In addition, the following occurs;
  18. 18. Cont.. • Fetal distress syndrome due to insufficient oxygen supply to the fetus • Respiratory distress syndrome is due to anoxia or meconium aspiration. • Oligohydraminious occurs due to reduced urine output by the fetus if it is stressed and can lead to umbilical cord compression. • Hypoglyceamia due to too little glucose producing in stores.
  19. 19. MATERNAL RISKS • Risk of perineal tears(third and fourth degree perineum lacerations) due to macrosomia • Assisted instrumental delivery such as forceps and vacuum extraction. • Caesarian section due to macrosomia which may present as cephalo pelvic disproportion.
  20. 20. Cont… • Psychological disturbances like anxiety and/or depression due to current pregnancy going beyond the expected date of delivery. • Postpartum haemorrhage resulting from invasive procedures like assisted instrumental delivery.
  21. 21. MANAGEMENT OF PROLONGED PREGNANCY • The management is usually individualised. • The pregnant woman should be made aware that management may alter depending on the clinical assessment. • The patient will need pre labour counseling and will need to be kept fully informed about the decisions taken. • There is a trend nowadays to be more conservative as long as there are no complications.
  22. 22. Cont… • If conservative management is chosen, the midwife must remain alert for signs of deterioration in the maternal and fetal conditions. • This will be achieved by antenatal surveillance, done as follows:
  23. 23. Cont… Fetal kick count: • The mother is required to do a daily kick count by counting the number of fetal movements felt in a given period of time e.g.12 hours and record on the kick chart. • When less than 10 fetal movements are felt during a 12 hour period, the fetus is considered to be at risk.
  24. 24. Cont… The biophysical profile test: • This involves doing scoring ultra sound assessment of the heart rate, fetal movement, fetal tone, reactivity of the heart rate and amniotic fluid volume to predict fetal well-being. • This is done twice weekly to monitor the fetal well-being.
  25. 25. Cont… Cardiotocography (CTG): • CTG is also known as non-stress testing (NST). • The fetal heart is monitored and the trace is assessed for the presence of reactivity and whether the baseline rate is within the normal range. • This is done twice weekly to monitor the fetal well-being.
  26. 26. Cont…. Amniotic fluid measurement: • Oligohydramnios can be noticed when doing abdominal examination. • On inspection, the abdomen appears smaller than the expected gestational age especially when IUGR is present. • On palpation, the uterus is small and compact, and fetal parts are easily felt. • Oligohydramnios is also detected by ultrasound and amnioscopy.
  27. 27. Cont… Doppler ultrasound of umbilical artery- • This is used to assess fetal and placental blood flow. • This could help in predicting a risk of fetal distress in labour. • Plasma or urinary oestriol levels can be performed to detect placental insufficiency where ultrasound is not available.
  28. 28. Cont… Maternal Assessment • The maternal condition will also be assessed to rule out any risk factors such as sudden weight gain, rising in blood pressure and proteinuria which would indicate the pre-eclampsia. • The midwife must also assess the woman’s psychological condition and keep her fully informed of her progress.
  29. 29. INDUCTION OF LABOUR • This refers to stimulation of uterine contractions prior to the onset of spontaneous labour. REQUIREMENTS FOR INDUCTION OF LABOUR • Ensure that the pregnancy is term (37 to 42 weeks). • Presentation must be cephalic and engaged.
  30. 30. Cont… • Pelvimetry should be done to ensure adequate pelvis. • Amniocentesis should be done to assess fetal lung maturity. • A cervical examination should be performed before initiating attempts at labour induction. • Assessment of cervical ripeness using Bishop scoring.
  31. 31. Cont…
  32. 32. Cont… • Bishop score is calculated based upon the station of the presenting part and cervical dilation, effacement, consistency and position. • Likelihood of a vaginal delivery after labour induction is similar to that after spontaneous onset of labour if the Bishop score is 8.
  33. 33. PROCESS OF LABOUR INDUCTION. Using prostaglandin E1(misoprostol) • A ripening process should be considered prior to use of oxytocin use when the cervix is unfavorable. • Synthetic prostaglandin E1(,misoprostol) is given in a dose of 25micograms vaginally every 4 to 6hours until uterine contractions are 3 in 10 minutes (maximum of 6 doses) especially if the Bishop score is less than 5.
  34. 34. Cont… • An oxytocin infusion may be started if there is; 1. no adequate contraction pattern, 2. the Bishop score is greater than 5, 3. it has been atleast 3 hours since the last dose of misoprostol.
  35. 35. Cont… Using oxytocin • The uterine response to exogenous oxytocin administration is periodic uterine contractions. • Oxytocin is given intravenously depending on the woman’s parity. • For prime gravidas 5iu is given in 1000mls of normal saline/dextrose/Ringer. For multi gravid 2 to 5iu in 1000mls of normal saline is given in grand multi para.
  36. 36. • Initial dose is 5drops per minute, increase every 30 minutes with 5 drops until the uterus contracts 2 contractions in 10 minutes. • Maximum being 30 drops per minute and this should not exeeced 1500mls in 10 hours (Sellers 2012). • However, progress of labour is closely monitored as a labour is induced.
  37. 37. Cont… • This is an active approach to post-term pregnancy where labour is induced. • Labour is induced if there is potential harm on the mother or fetus. • Together with standard care of a woman in labour, the following specialized care given: • Strict monitoring of fetal condition with cardiotocography throughout the labour or ¼ hourly monitoring of fetal heart rate where CTG is not available.
  38. 38. Cont… • Prevention of supine hypotension syndrome. • Preparation for possible resuscitation of the infant; all resuscitative equipment should be prepared and paediatrician called to assist in resuscitation. • Changes in baby`s condition may require caesarean section delivery.
  39. 39. Caesarian section Considered if: • The woman is more than 30 years of age, particularly with history of previous infertility. • The baby is large, that is over 4kg. • The cervix is unripe. • Insufficient placental reserve • Gestational proteinuria hypertension.
  40. 40. CHARACTERISTICS OF POST MATURE NEONATE • A long thin body appearance because the neonate have decreased amount of soft tissue mass particularly subcutaneous fat. • Deep cracking and peeling skin due to placental aging and continuity exposure to amniotic fluid. • The skull is hard, with narrow sutures and small fontanelles.
  41. 41. Cont…. • The genitalia are fully developed. For example; a male baby will have a lot of rugae on the scorotum and if it’s a female baby, the labia minora will be well covered with the labia majora. • The toe and finger nails are long and stained with meconium. • The skeleton is fully developed.
  42. 42. Cont… • The ear cartilage firm and the breast bud tissue are palpable. • The skin is often dry, loose, and peeling due to decreased subcutaneous tissue. • The skin may be meconium stained resulting from meconium passed in utero due to hypoxia.
  43. 43. PROBLEMS ASSOCIATED WITH POST MATURITY FETAL DISTRESS • The effect of uterine contractions on an already compromised placenta may cause fetal hypoxia causing the fetus to be distressed. MECONIUM ASPIRATION. • Hypoxia and distress may cause relaxation of the anal sphincter leading to the passage of meconium while in utero. • The fetus can aspirate the meconium stained liquor into the lungs either in utero or during delivery.
  44. 44. Cont… HYPOGLYCEAMIA • May result from nutritional deprivation and resultant depleted glycogen stores. HYPOTHERMIA • This is due to decreased liver glycogen and brown fat stores. • This is due to reduced fats which act as an insulator.
  45. 45. Cont…. POLYCYTHERMIA • This is the increase in the red blood cell production coming in as a result of hypoxia. BIRTH INJURIES • There will complete ossification of the skull bones leading to poor moulding which contributes to birth injuries
  46. 46. Cont… SEIZURES • The neonate can have episodes of seizures which can come as a result of the hypoxia experienced during intra uterine INTRA UTERINE DEATH • This can result from acute fetal hypoxia while it is in uterus and this can lead to fetal death
  47. 47. MANAGEMENT OF A POST MATURE BABY • The management is directed at differentiating the fetus that has post maturity syndrome from the one who is large, well nourished and tolerated the prolonged pregnancy. • Our goal of management is to identify and manage the post mature newborn’s potential problems
  48. 48. Cont… PSYCHOLOGICAL SUPPORT • Provide emotional support to the parents to encourage them as the neonate may appear with dry cracking skin and possible aspiration of meconium. • Explain all the procedures in order to obtain co- operation.
  49. 49. Cont…. MANTAINING A CLEAR AND PATENT AIR WAY • If the amniotic fluid is meconium stained the baby’s nose and mouth should be wiped before the baby takes its first breath to minimize the chances of meconium aspiration syndrome . • After birth the direct suctioning of the trachea is needed.
  50. 50. Cont… OBSERVATION • Observe the cardiopulmonary function of the neonate because of the stress of labour which is poorly tolerated by the post mature infant and may lead to severe birth asphyxia. • Monitor the apical beat of the neonate which should be in the range of 120b/m to 160b/m as well as the respirations which should be between 30 to 60 b/m.
  51. 51. Cont… • Monitor the skin colour as these neonates tend to be cyanosed as well as jaundiced. • There is also need to observe for the occurrence of convulsions which are likely to be experienced by the neonate. • Observe for any injury the neonate can sustain such cephalo heamatoma and caput succedenum. • Other observations are as for any normal neonate.
  52. 52. cont PROVISION OF WARMTH • The post mature neonate tends to suffer from hypothermia because of their reduced fat stores. • The neonate can be nursed together with the mother through skin to skin contact hence provision of warmth from the mother more especially if the condition is stable.
  53. 53. Cont… • If the condition of the neonate needs interventions from neonatal intensive care unit then the neonate can be nursed in the pre warmed incubator with an incubator temperature of (32.5 to 37.7 degrees celcious). • The environment should be warm enough to provide enough heat to the neonate as this baby has low glycogen and brown fat stores
  54. 54. PREVENTION OF HYPOGLYCAEMIA • If the the neonate is unable to suck. Intravenous fluid of 10 % of dextrose can be given. • This can be followed by breast feeding either expressed or cup and spoon type of feeding until such a time a baby can breast feed on its own. • Early initiation of feeding is very important to prevent hypoglycaemia (within 1 hour) after delivery. • Frequent monitoring of blood glucose is very cardinal to ensure that the neonate is not in a state of hypoglycemia.
  55. 55. SUMMARY • Pregnancy is considered prolonged exceeds 294 days or 42 weeks from the first day of the last monthly period. • Of all the pregnancies, 12% are post-term (Paul.D 2006). • Chances of post-term pregnancies are higher in first pregnancies and in women who have had a previous post-term pregnancy. • The worry with post-term pregnancy is placental insufficiency.
  56. 56. Cont…. • Labour may progress well as spontaneous vaginal delivery provided she is monitored closely in the antenatal period and much more during labour. • Induction of labour or caesarian section can be done depending on the condition of both the mother and the fetus. • Therefore,the expectant woman needs to be prepared psychologically before these procedures to gain her co-operation and allay anxiety.
  57. 57. REFERENCES. • Aaron,B.C.emedicine.Medscape.com/articl e/2613369-overview (2013), Time 16:40PM date 18/01/2016. • Fraser and cooper (2003). Myles Textbook for Midwives, 14th edition, Churchill Livingstone, London. • Gloria, L. (1999). Introduction to Maternity and Peadiatric Nursing, 3rd edition, Philadelphia, London.
  58. 58. Cont… • Paul, D. et al (2006). Gynaecology and Obstetrics, Laguna Hills, California, USA. • Marcia, L. et al (2007). Maternal and Child Nursing Care, 2nd Edition, Elsevier United States Of America. • Murray, S.M. and Mckinney E.S (2006). Foundation of Maternal-New born Nursing, Elsevier, United States Of America. • Sellers, P.M. (2012) Midwifery Text Book. 2nd edition, Juta & Company Ltd, South Africa.