1. ProlongedProlonged
pregnancypregnancy
&&
Induction ofInduction of
labourlabour
Dr. Ufaque BatoolDr. Ufaque Batool
House OfficerHouse Officer

2. Prolonged pregnancyProlonged pregnancy
IntroductionIntroduction:-:-
Prolonged pregnancy is a condition thatProlonged pregnancy is a condition that
continuous to evoke anxiety in clinician andcontinuous to evoke anxiety in clinician and
woman alike and is perceived as being awoman alike and is perceived as being a
cause of increased risk to the fetuscause of increased risk to the fetus..

3. objectiveobjective:-:-
Our aim from this lecture be able toOur aim from this lecture be able to::
Understand the definition of prolongedUnderstand the definition of prolonged
pregnancy and distinguish it from postpregnancy and distinguish it from post
maturity syndromematurity syndrome..
Understand the options in the managementUnderstand the options in the management
of prolonged pregnancyof prolonged pregnancy..
Counsel a woman about the risk ofCounsel a woman about the risk of
prolonged pregnancyprolonged pregnancy..

4. DefinitionDefinition:-:-
The standard international definition ofThe standard international definition of
prolonged pregnancy by WHOprolonged pregnancy by WHO 4242 completedcompleted
weeks or more(weeks or more(294294 days or more) from first daydays or more) from first day
of last menstrual periodof last menstrual period..

5. IncidenceIncidence:-:-
Between (Between (4-144-14)% will reach this gestation)% will reach this gestation..
Its recognized that woman who attend late forIts recognized that woman who attend late for
antenatal care may be unsure of her LMPantenatal care may be unsure of her LMP..
Dating by last menstrual period alone hasDating by last menstrual period alone has 70%70%
tendency to over estimate the gestational agetendency to over estimate the gestational age
(delayed ovulation(delayed ovulation(.(.

6. ContCont......
Actual true rate is (Actual true rate is (3-53-5)% when based on)% when based on
ovulation dateovulation date..
Routine use of early ultra sound toRoutine use of early ultra sound to
calculate gestational age reducecalculate gestational age reduce
incidence fromincidence from 9.5%9.5% toto 1.5%1.5%..
Most pregnancies that reliablyMost pregnancies that reliably 4242 weeksweeks
probably are not biologically prolongedprobably are not biologically prolonged..

7. Aetiology and pathologyAetiology and pathology:-:-
The cause of prolonged pregnancy is not clearThe cause of prolonged pregnancy is not clear
may represent simple biological variationmay represent simple biological variation..
Prolonged pregnancy more common in PGProlonged pregnancy more common in PG..
Prolonged pregnancy more common with HOProlonged pregnancy more common with HO
previous Prolonged pregnancyprevious Prolonged pregnancy 30%30%..
Infant who suffered fetal distressInfant who suffered fetal distress at termat term hadhad
elevatedelevated cortisol levelcortisol level..

8. ContCont……
Infant who suffered fetal distress atInfant who suffered fetal distress at prolongedprolonged
pregnancypregnancy hadhad reducedreduced cortisol levelcortisol level..
Relative Adreno cortical insuffiency delay in onset ofRelative Adreno cortical insuffiency delay in onset of
labour, increase risk of intra partum hypoxia, deathlabour, increase risk of intra partum hypoxia, death
in prolonged pregnancyin prolonged pregnancy..
Amniotic fluid fall in prolonged pregnancyAmniotic fluid fall in prolonged pregnancy..
Normal cardiac outputNormal cardiac output..
Doppler velocimetry in uterine, umbilical, middleDoppler velocimetry in uterine, umbilical, middle
cerebral no difference from term pregnancycerebral no difference from term pregnancy..

9. Clinical approachClinical approach:-:-
Accurate diagnosis of prolonged pregnancyAccurate diagnosis of prolonged pregnancy
relies up on either accurate menstrual data orrelies up on either accurate menstrual data or
routine ultra sound inroutine ultra sound in 11stst
oror 22ndnd
trimestertrimester
beforebefore 20 weeks20 weeks if she is not sure of her dateif she is not sure of her date
of LMPof LMP..

10. A-HistoryA-History:-:-
Confidence in the menstrual historyConfidence in the menstrual history..
The LMP tend to be accurate ifThe LMP tend to be accurate if:-:-
The patient sure of her dateThe patient sure of her date..
The pregnancy was plannedThe pregnancy was planned..
The cycle was regularThe cycle was regular..
No resent history of oral contraceptive ,No resent history of oral contraceptive ,
abortion or lactationabortion or lactation..

11. B-Clinical parametersB-Clinical parameters:-:-
 Uterine sizeUterine size  vaginal examination in 1vaginal examination in 1stst
trimester useful intrimester useful in
determing gestational agedeterming gestational age..
Fundal heightFundal height  abdominal examinationabdominal examination..
 QuickeningQuickening  maternal reporting first fetal movementmaternal reporting first fetal movement..
 Fetal heartFetal heart  heard by fetoscope at (heard by fetoscope at (18-2018-20)weeks)weeks..

12. C-Ultra sound parametersC-Ultra sound parameters:-:-
Crown-Rump length (CRL) at (Crown-Rump length (CRL) at (7-10W7-10W)) ±± 55daysdays
Biparietal diameter (BPD) at (Biparietal diameter (BPD) at (18-22W18-22W)) ±± 77daysdays

13. Fetal and neonatal risks of prolongedFetal and neonatal risks of prolonged
pregnancypregnancy
11--perinatal morbidity & mortality is increasedperinatal morbidity & mortality is increased 2-32-3 timestimes
than normalthan normal..
22--post maturity syndromepost maturity syndrome::
Post mature infant features include wrinkled, patchy,Post mature infant features include wrinkled, patchy,
peeling skin along this body suggesting wastingpeeling skin along this body suggesting wasting..
Occur inOccur in 20-30 %20-30 % of prolonged pregnancyof prolonged pregnancy
characterized by the followingcharacterized by the following:-:-
AA-aging or infarction of placenta lead to utero-aging or infarction of placenta lead to utero
placenta insuffiency which result in decreaseplacenta insuffiency which result in decrease
oxygenation (fetal hypoxia) and decreaseoxygenation (fetal hypoxia) and decrease
maturation (decrease sub cutaneous tissuematuration (decrease sub cutaneous tissue(.(.

14. BB-oligohydramnious which cause umbilical-oligohydramnious which cause umbilical
cord compressioncord compression..
CC-passage of meconium in utero-passage of meconium in utero..
33--macrosomic fetusmacrosomic fetus::
Weight >(Weight >(4000-45004000-4500)gm occur in)gm occur in 7070-- 80%80%
leads toleads to::
abnormal labourabnormal labour..
shoulder dystochiashoulder dystochia..
birth traumabirth trauma..

15. Maternal risks of prolongedMaternal risks of prolonged
pregnancypregnancy
 Psychological morbidityPsychological morbidity..
The pregnancy is perceived by many womanThe pregnancy is perceived by many woman
as becoming high risk once EDD isas becoming high risk once EDD is
passedpassed..
 Increased operative delivery (csIncreased operative delivery (cs(.(.
 Increased risk of hemorrhage (prolongedIncreased risk of hemorrhage (prolonged
labourlabour(.(.
 Increased risk of infectionIncreased risk of infection..

16. ManagementManagement:-:-
Successful management of prolonged pregnancySuccessful management of prolonged pregnancy
depend on effective counselling of a womandepend on effective counselling of a woman
and their full involvement in the decisionand their full involvement in the decision
making processmaking process..
A-A-if the date are confirmed and the cervix areif the date are confirmed and the cervix are
favourablefavourable..
 Labour should be inducedLabour should be induced::
artificial rupture of membrane (artificial rupture of membrane (AROMAROM(.(.
intra venous (intra venous (IVIV)) oxytocinoxytocin..
 Continous intra partum fetal monitoring watching forContinous intra partum fetal monitoring watching for:-:-
variable deceleration (cord compressionvariable deceleration (cord compression(.(.
late decceleration (Utero Placental Insuffiency)(UPIlate decceleration (Utero Placental Insuffiency)(UPI(.(.

17. B-B-if the date are confirmed and the cervix isif the date are confirmed and the cervix is
unfavourable there is two optionsunfavourable there is two options:-:-
Induce labourInduce labour:-:-
using prostaglandinusing prostaglandin E2E2..
ConservationConservation:-:-
both the non stress testboth the non stress test NSTNST AmnioticAmniotic
fluid indexfluid index AFIAFI should be performedshould be performed
twice weeklytwice weekly..
Delivery should take place if theDelivery should take place if the NSTNST
become non reactive or If thebecome non reactive or If the AFIAFI isis
<5<5 cm orcm or <2<2 cm depth of largestcm depth of largest
vertical polevertical pole..

18. C-C- if the date are uncertainif the date are uncertain:-:-
Both theBoth the NST & AFINST & AFI can be performed twicecan be performed twice
weekly while waiting for spontaneous labourweekly while waiting for spontaneous labour
to occurto occur..
Delivery should take place if theDelivery should take place if the NSTNST
become non reactive or if thebecome non reactive or if the AFI <5AFI <5 cmcm..

19. Induction ofInduction of
labourlabour

20. DefinitionDefinition:-:-
Induction of labour is the artificialInduction of labour is the artificial
initiation of uterine contractionsinitiation of uterine contractions
prior to their spontaneous onsetprior to their spontaneous onset
leading to progressive dilatation andleading to progressive dilatation and
delivery of the babydelivery of the baby..
IncidenceIncidence:-:-
Variable (Variable (15-2015-20(%.(%.

21. IndicationIndication:-:-
The purpose of an induction is toThe purpose of an induction is to
achieve benefit to the health of theachieve benefit to the health of the
mother and or baby when theirmother and or baby when their
suspected or confirmed risk tosuspected or confirmed risk to
mother and or babymother and or baby..

22. 11--Maternal diseasesMaternal diseases:-:-
 DiabetesDiabetes..
 Hypertention renal diseasesHypertention renal diseases..
 cardiac diseasecardiac disease..
22--pregnancy – related conditionspregnancy – related conditions:-:-
 pre eclampsiapre eclampsia..
 intra hepatic choleostasis of pregnancyintra hepatic choleostasis of pregnancy..
 APH at termAPH at term..
 placental abruptionplacental abruption..
33--fetal indicationfetal indication:-:-
 intra uterine growth restrictedintra uterine growth restricted..
 oligohydramniousoligohydramnious..
 Iso immunizationIso immunization..

23. 44--Pregnancy passing 41 weeksPregnancy passing 41 weeks..
55--Pre-labour spontaneous rupturePre-labour spontaneous rupture
of membrane (PLROMof membrane (PLROM(.(.
66--Maternal requestMaternal request..

24. **Assessment before induction commenceAssessment before induction commence:-:-
The obstetrician should assess the balanceThe obstetrician should assess the balance
between the risk associated with allowing thebetween the risk associated with allowing the
pregnancy to continue and those associated withpregnancy to continue and those associated with
interrupting itinterrupting it::
11--confirmation of gestational ageconfirmation of gestational age::
to avoid risk of iatrogenic prematurityto avoid risk of iatrogenic prematurity..
 History – LMPHistory – LMP..
 ExaminationExamination..
 US ScanUS Scan..

25. 22--Are there mechanical impedance toAre there mechanical impedance to
deliverydelivery?.?.
 DisproportionDisproportion..
 Pelvic tumourPelvic tumour..
 Placenta previaPlacenta previa..
33--What is the condition of cervixWhat is the condition of cervix
assisted by bishop score (1964assisted by bishop score (1964(.(.

26. Bishop scoreBishop score
factors
SCORE DILATATION EFFACEMENT STATION CERVICAL CERVICAL
CM % -)3+ - 3( CONSISTENCY POSITION
0 closed 0-30% -3 firm posterior
1 1-2 40-50% -2 medium Mid
position
2 3-4 60-70% -1 soft anterior
3 ≤≤5 ≤≤80% +1+,2 _ _

27. **Methods of inductionMethods of induction:-:-
11--MedicalMedical:-:-
 ProstaglandinProstaglandin..
 OxytocinOxytocin..
22--SurgicalSurgical:-:-
 Membrane sweepingMembrane sweeping..
 AmniotomyAmniotomy..
33--CombinationCombination
44--Agents currently researchedAgents currently researched:-:-
 Nitric oxide donorsNitric oxide donors..
 Anti progestogens (Anti progestogens (Ru-486Ru-486(.(.
 Inter-leukin-Inter-leukin-88..
 RelaxinRelaxin..

28. 11--Medical methodsMedical methods:-:-
If the cervix is unfavorable (un-If the cervix is unfavorable (un-
riperipe(:-(:-
prostaglandinprostaglandin::
 local vaginal administrationlocal vaginal administration:-:-
 tablet (tablet (0.5 mg0.5 mg(.(.
 pessary (pessary (3 mg3 mg(.(.
 gelly (gelly (1 mg1 mg(.(.
 side effect of prostaglandinside effect of prostaglandin:-:-
 Gastro intestinal upsetGastro intestinal upset..
 Uterine hyper stimulation (rareUterine hyper stimulation (rare(:-(:-
defined as six or more contractions indefined as six or more contractions in 1010 minutesminutes
or a single contraction lastingor a single contraction lasting >> 22 minutesminutes..

29. If cervix is favourable (ripeIf cervix is favourable (ripe(:-(:-
oxytocinoxytocin::
 its octa peptide hormone secreted from para ventricularits octa peptide hormone secreted from para ventricular
and supra optic nuclei of hypothalamus, stored inand supra optic nuclei of hypothalamus, stored in
posterior pituitary and released in pulsatile mannerposterior pituitary and released in pulsatile manner..
 Oxytocin is administered in synthetic form pitocin orOxytocin is administered in synthetic form pitocin or
syntocinon used by continous I.V infusion (pump orsyntocinon used by continous I.V infusion (pump or
drip) after amniotomy to stimulate uterine contraction,drip) after amniotomy to stimulate uterine contraction,
also used to augment and accelerate labouralso used to augment and accelerate labour..

30.  The usual dose isThe usual dose is 55 IUIU500500 ml normal salineml normal saline..
rate to be increased everyrate to be increased every 3030 minute untilminute until
satisfactory contraction are establishedsatisfactory contraction are established..
not exceedingnot exceeding 6060 Dropsmin orDropsmin or 3232 m Unit minutem Unit minute..
side effectsside effects:-:-
uterine hyperstimulationuterine hyperstimulation..
poor uterine contractionpoor uterine contraction..
Anti diuretic effectAnti diuretic effect..
 rupture of uterusrupture of uterus..
 Neonatal hyperbilirubinemiaNeonatal hyperbilirubinemia..

31. 22--Surgical methodsSurgical methods:-:-
A-membrane sweepingA-membrane sweeping:-:-
increased likelihood of spontaneous labourincreased likelihood of spontaneous labour
withinwithin 4848 hours due to local release ofhours due to local release of
prostaglandinprostaglandin..
B-Amniotomy (AROMB-Amniotomy (AROM(:-(:-
Fore-water amniotomyFore-water amniotomy:-:-
AmniohookAmniohook..
Toothed forcepsToothed forceps..
Hind-water amniotomyHind-water amniotomy:-:-
Drew-somyth catheterDrew-somyth catheter..

32.  The success of amniotomy is dependent uponThe success of amniotomy is dependent upon
the state of cervix, the parity of woman andthe state of cervix, the parity of woman and
the station of presenting part at time ofthe station of presenting part at time of
interventionintervention..
ComplicationsComplications:-:-
 failure to induce effective contractionsfailure to induce effective contractions..
 bleedingbleeding  damage to the cervixdamage to the cervix..
 placental separation due to sudden reductionplacental separation due to sudden reduction
of the volume of liquorof the volume of liquor..
 infectionsinfections..
 amniotic fluid embolismamniotic fluid embolism..

33. 33--combined surgical and medicalcombined surgical and medical
inductioninduction:-:-
Surgical amniotomy followed by oxytocin useSurgical amniotomy followed by oxytocin use..

34. THE ENDTHE END
Thanks for yourThanks for your
attentionattention