4. Contd…
Thrombophilias: Factor V Leiden, Protein C, Protein S
deficiency
Abnormal labor(prolonged or obstructed labor, ruptured
uterus)
Post-term pregnancy
Systemic lupus erythematosus
7. SIGN & SYMPTOMS
Symptom- Absence of fetal movements which were previously
noted by the patient.
Sign- Retrogression of the positive breast changes that occur
during pregnancy is evident after viable period following death of
the fetus.
Per abdomen:
Gradual retrogression of the fundal height & it becomes smaller
than the period of gestation.
Fetal movements are not felt during palpation.
Fetal heart sound is absent. Use of Doppler ultrasound is better
than the stethoscope.
Egg-shell cracking feel of the fetal head is a late feature.
8. INVESTIGATION
1. SONOGRAPHY
Lack of all fetal motions during a 10 minute period of careful
observation with a real-time sonar is a strong presumptive
evidence of fetal death.
Oligohydramnios & collapsed cranial bones are evident.
2. STRAIGHT X-RAY ABDOMEN
Spalding sign: The irregular overlapping of the cranial bones on
one another is due to liquefaction of the brain matter & softening
of the ligamentous structures supporting the vault.
Hyperflexion of spine is more common. Crowding of the ribs
shadow with loss of normal parallelism. Appearance of gas shadow
( Robert’s sign) in the chambers of the heart & great vessels may
appear as early as 12 hours but difficult to interpret.
9. MANAGEMENT
Prevention:
The overall risk of recurrence of stillbirth varies between 0% &
8%. The conditions that run the risks of recurrence are:
hereditary disorders, diabetes, hypertension, thrombophilias,
placental abruption & fetal congenital malformations.
Pre-conceptional counseling & care
Prenatal diagnosis
To screen the “at-risk-mothers” during antenatal care
Expectant attitude ( Non-interference):
The patient & her relatives are likely to be upset psychologically
but they should be assured of safety of non-interference. In
about 80% of cases, spontaneous expulsion occurs within 2 weeks
of death.
10. Contd..
Reasons for early delivery:
Reliable & early diagnosis could be made with real time
ultrasonography.
Prostaglandins are available for effective induction.
Complications could be avoided.
Indications of early Interference:
Psychological upset of the patient-common.
Manifestations of uterine infections.
Tendency of prolonged pregnancy beyond 2 weeks.
Falling of fibrinogen level.
11. Contd…
Method of delivery:
A combination of mifipristone & a prostaglandin preparation is
recommended as the first-line choice for induction of labor. A
single dose (200mg) of oral mifepristone & misorostol intravaginal
25 microgram 4 hoursly are safe, effective & of low cost.
Induction delivery interval was 8 hours. Mifepristone (600mg
daily for 2 days) alone can be used for induction also.
Misoprostol 25-50 microgram either vaginally or orally is also
found effective. Vaginal route use is more effective compared to
oral route, may be repeated every 4 hours. Misoprostol is
preferred to oxytocin as it is safe, effective & cheap.
12. Prostaglandins gel or lipid pessary vaginally administration in the
posterior fornix is very effective for induction where the cervix is
unfavorable. This may have to be repeated after 6-8 hours. The
procedure may be supplemented with oxytocin infusion.
Oxytocin infusion is widely practiced & effective in case where the
cervix is favorable. To begin with 5-10 units of oxytocin in 500ml RL
is administered through intravenous infusion drip. In case of failure,
an escalating dose of oxytocin is used on the next day. To start with ,
a drip is set up with 20 units of oxytocin in 500 ml of RL & run 30
drops per minute. Oxytocin infusion may be used as a
supplementary therapy when vaginal prostaglandins are used.
13. Contd…
Induction of labor in women with previous LSCS:
PGE2 gel may be used safely in women with previous one
LSCS, but for women with previous two LSCS, risk
(rupture uterus) is slightly more.
Bereavement management & puerperium:
The medical team & the nursing staff should provide all the
support & bereavement to the couple. The risk of post-
partum depression is high. The couple is seen in the post-
partum clinic after 6 weeks. Counselling for future
pregnancy is to be done.
15. INCIDENCE
The incidence of pregnancies continuing beyond 42 completed
weeks ranges between 4% to 14%. The average is about 10%. Many
suspected post-term pregnancies are actually wrongly dated.
ETIOLOGY
Wrong dates
Biological variability
Maternal factors (Primiparity, previous prolonged pregnancy,
sedentary habit, elderly primigravida)
Fetal factors ( Congenital anomalies)
Placental factor ( Sulfatase deficiency-low estrogen)
16. ASSESSMENT OF FETAL MATURITY
SONOGRAPHY
Estimation of gestational age by early (1st trimester) ultrasound is more
accurate than by L.M.P. This is mainly due to poor recall of L.M.P by
most patients & secondly LMP is not a good predictor of ovulation.
AMNIOCENTESIS
The biochemical & cytological parameters are helpful.
Assessment of fetal wellbeing is done by twice weekly NST,
biophysical profile & ultrasound estimation of amniotic fluid volume.
Doppler velocimetry study of umbilical & middle cerebral arteries
waveform are informative.
17. CLINICAL CONCEPT
General appearance ( Baby looks like thin & old. Skin is wrinkled.
There is absence of vernix caseosa. Body & cord are stained with
greenish yellow color. Head is hard without much evidence of
moulding. Nails are protruding beyond the nail beds.)
Weight ( Often more than 3 kg & length is about 54 cm.)
Liquor amnii ( Scanty & may be stained with meconium)
Placenta ( There is evidence of aging of the placenta manifested
by excessive infarction & calcification.)
Cord (There is diminished quantity of Wharton’s jelly)
18. MANAGEMENT
UNCOMPLICATED:
Selective induction- In this regimen, the pregnancy may be allowed to
continue still spontaneous onset of labor. Fetal surveillance is continued
twice a week.
Routine induction- The expectant attitude is extended for 7-10 days past
the expected date & thereafter labor is induced.
Induction:
Induction of labor reduces the rate of CS & perinatal mortality.
If the cervix is favorable, induction is to be done by stripping of the
membranes or by low rupture of the membrane. If the liquor found clear,
oxytocin infusion is added to be more effective. Careful monitoring is
mandatory.
If the cervix is unripe, it is made favorable by vaginal administration of
PGE2 gel. This is followed by low rupture of membrane. Oxytocin infusion
is added when required.
19. Contd…
COMPLICATED:
Elective CS is advisable when postmaturity is associated with
high risk factors like- elderly primigravida, pre-eclampsia, Rh-
incompatibility, Fetal compromise, Oligohydramnios.
Care during labor:
Whether spontaneous or induced, the labor is expected to be
prolonged because of a big baby & poor moulding of the head.
More analgesia is required for pain relief. Possibility of shoulder
dystocia is to be kept in mind. Careful fetal monitoring with
available gadgets is to be done.
If fetal distress appears, prompt delivery either by CS or by
forceps/ventouse is to be done.
20. JOURNAL ARTICLE
“To Determine the Effects of Labor Induction on Maternal and
Fetal Outcome in Post-term Pregnancies (41 Weeks Plus) “- Milad
M. M. Gahwagi, Farag Benali, Nagat M. Bettamer, Asma Soliman Zubi
Aim of the Work:
The aim of this study was to determine the effect of labor induction
on maternal and fetal outcome in post-term pregnancies.
Subjects and Methods:
This study was carried out on 150 pregnant women who had completed
41 weeks of gestation between Jun. 1, 2012 up to Dec. 31, 2012 at D
epartment of Obstetrics & Gynecology and were scheduled for
induction of labor after cardiotocography (CTG) and
ultrasonography (USG) have been done and Bishop’s score
assessed, to determine the effects of labor induction on maternal
and fetal outcome in postterm pregnancies (41 weeks plus).
21. Contd…
Results:
Regarding the relationship between a history of (H/O) postdatism
and fetal distress, it was found that there was no significant
relationship between them. There was a significant relationship
between a history of macrosomia and fetal distress. There was
a significant relationship between instrumental delivery and
fetal distress. The majority of the fetal distress had an indication
for Caesarean section (CS).There was a significant relationship
between the APGAR score at 10 minutes with fetal distress. All
fetuses that had meconium aspiration had fetal distress. There
was a significant increase in the amount of oxytocin in unit in
distressed cases than the non-distressed ones. The total
duration of induction was also significantly increased in stressed
fetuses than the non-stressed ones. There was a significant
increase in the weight of distressed fetuses than the non-
distressed.
22. Contd…
Conclusion:
In conclusion, there was no difference in the neonatal outcome or
mode of delivery for post-term pregnancies managed either by
immediate induction of labor or expectantly with serial antenatal
surveillance. The outcomes were generally good, and neonatal
morbidity, cesarean section, and operative vaginal delivery rates
were low. If pregnancy is uncomplicated and continued surveillance
is possible, women’s own wishes may guide the decision to induce or
monitor a pregnancy beyond 41 weeks.
