1.
PROLONGED
PREGNANCY/POSTMATURITY
MRS KATOLO

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.
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.
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.
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.
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.
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.
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.
ABBREVIATIONS
• Intra uterine growth retardation (IUGR);
• Expected date of delivery (EDD);
• Last monthly period (LMP)

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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Cont…

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.
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.
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.
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.
• 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.