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Diagnosis of malpresentations

Symptoms and Signs


BROW PRESENTATION is caused by partial extension of the
fetal head so that the occiput is higher than the sinciput (Fig S16).

Figure
FIGURE S-16

On abdominal examination, more than half the fetal


head is above the symphysis pubis and the occiput is
palpable at a higher level than the sinciput.
On vaginal examination, the anterior fontanelle and the
orbits are felt.
For management
FACE PRESENTATION is caused by hyper-extension
of the fetal head so that neither the occiput nor the
sinciput are palpable on vaginal examination (Fig S-17
and Fig S-18).

FIGURE S-17

On abdominal examination, a groove may be felt


between the occiput and the back.
On vaginal examination, the face is palpated, the
examiners finger enters the mouth easily and the bony
jaws are felt.

FIGURE S-18

For management
COMPOUND PRESENTATION occurs when an arm prolapses
alongside the presenting part. Both the prolapsed arm and the
fetal head present in the pelvis simultaneously (Fig S-19).
For management

FIGURE S-19

BREECH PRESENTATION occurs when the buttocks and/or


the feet are the presenting parts.

FIGURE S-20

On abdominal examination, the head is felt in the upper


abdomen and the breech in the pelvic brim. Auscultation
locates the fetal heart higher than expected with a vertex
presentation.
On vaginal examination during labour, the buttocks and/or
feet are felt; thick, dark meconium is normal.
For management

COMPLETE (FLEXED) BREECH PRESENTATION


FIGURE S-21
occurs when both legs are flexed at the hips and knees (Fig S20).
FRANK (EXTENDED) BREECH PRESENTATION
occurs when both legs are flexed at the hips and extended at
the knees (Fig S-21).

FOOTLING BREECH PRESENTATION occurs when a leg is


extended at the hip and the knee (Fig S-22).
FIGURE S-22

TRANSVERSE LIE AND SHOULDER PRESENTATION occur


when the long axis of the fetus is transverse (Fig S-23). The
shoulder is typically the presenting part.

FIGURE S-23

On abdominal examination, neither the head nor the buttocks


can be felt at the symphysis pubis and the head is usually felt in
the flank.
On vaginal examination, a shoulder may be felt, but not
always. An arm may prolapse and the elbow, arm or hand may
be felt in the vagina.
For management

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Introduction
Postterm pregnancy is defined as a pregnancy that extends to 42 0/7 weeks and beyond. 1 The
reported frequency of postterm pregnancy is approximately 3-12%. 1,2 However, the actual biologic
variation is likely less since the most frequent cause of a postterm pregnancy diagnosis is inaccurate
dating.3,4,5,6 Risk factors for actual postterm pregnancy include primiparity, prior postterm pregnancy,
male gender of the fetus, and genetic factors.7,8,9,2,1
Laursen et al studied monozygotic and dizygotic twins and their subsequent development of prolonged
pregnancies. They found that maternal but not paternal genetic factors influenced the rate of postterm
pregnancies and accounted for the etiology in as many as 30% of these pregnancies. 10 A more recently
described risk factor is obesity, which appears to increase the risk of pregnancies progressing beyond
41 or 42 weeks of gestation.11,12,13
Although the last menstrual period (LMP) has been traditionally used to calculate the estimated due
date (EDD), many inaccuracies exist using this method in women who have irregular cycles, have
been on recent hormonal birth control, or who have first trimester bleeding. In particular, women are
more likely to be oligo-ovulatory than polyovulatory, so cycles longer than 28 days are not uncommonly
seen.4 If such a cycle is 35 days instead of 28 days, a second trimester ultrasound will not be powerful
enough to redate the pregnancy. Thus, not only the LMP date, but the regularity and length of cycles
must be taken into account when estimating gestational age.
Ultrasonographic dating early in pregnancy can improve the reliability of the EDD; however, it is
necessary to understand the margin of error reported at various times during each trimester. A
calculated gestational age by composite biometry from a sonogram must be considered an estimate
and must take into account the range of possibilities.

Estimation range varies. For example, crown-rump length (CRL) is 3-5 days, ultrasonography
performed at 12-20 weeks of gestation is 7-10 days, at 20-30 weeks is 2 weeks, and after 30 weeks is
3 weeks. Thus, a pregnancy that is 35 weeks by a 31-week ultrasound could actually be anywhere
from 32 weeks to 38 weeks (35 wk +/-3 wk). If the calculated ultrasonographic gestational age varies
from the LMP more than the respective range of error, it is used instead to establish the final EDD. The
importance of determining by what method a pregnancy is dated cannot be overemphasized because
this may have significant consequences if the physician delivers a so-called term pregnancy that is not
or observes a so-called term pregnancy that is very postterm.
When determining a management plan for an impending postterm pregnancy (>40 wk of gestation but
<42 wk), the 3 options are (1) elective induction of labor, (2) expectant management of the pregnancy,
or (3) antenatal testing. Each of these 3 options may be used at any particular time during this 2-week
period.
Note that if the pregnancy is at risk for an adverse outcome from an underlying condition, either
maternal or fetal, inducing labor may proceed without documented lung maturity. Also, an elective
induction of labor may proceed at or after 39 weeks of gestation in the absence of documented lung
maturity provided that 36 weeks have elapsed since documentation of a positive human chorionic
gonadotropin (+hCG) test finding, 20 weeks of fetal heart tones have been established by a fetoscope
or 30 weeks by a Doppler examination, or 39 weeks' gestation have been established by a CRL or by
an ultrasound performed before 20 weeks of gestation consistent with dates by the patient's LMP.
Perinatal outcomes in postterm pregnancies
Recent studies have shown that the risks to the fetus 14,15,16,17,18,19,20,21,22,23,24,25,26 and to the mother23,27,28,29,30,31,32,33
of continuing the pregnancy beyond the estimated date of delivery is greater than originally
appreciated.
Risks have traditionally been underestimated for 2 reasons. First, earlier studies were published before
the routine use of obstetric ultrasonography and, as a result, likely included many pregnancies that
were not truly postterm. As noted above, such a misclassification bias would artificially lower the
complication rates of pregnancies designated postterm and increase the complication rates in those
designated term, resulting in a diminution in the difference between term and postterm pregnancies.
The second issue relates to the definition of stillbirth rates. Traditionally, stillbirth rates were calculated
using all pregnancies delivered at a given gestational age as the denominator. However, once a fetus
is delivered, it is no longer at risk of intrauterine fetal demise, and use of this denominator has
traditionally underestimated the risk of stillbirth. The appropriate denominator is not all deliveries at a
given gestational age, but ongoing (undelivered) pregnancies. 18,19,33 In one retrospective study of more
than 170,000 singleton births, for example, Hilder et al demonstrated that the stillbirth rate increased 6fold (from 0.35-2.12 per 1,000 pregnancies) when the denominator was changed from all deliveries to
ongoing (undelivered) pregnancies. 16
Fetal and neonatal risks
Antepartum stillbirths account for more perinatal deaths than either complications of prematurity or
sudden infant death syndrome.17 Perinatal mortality (defined as stillbirths plus early neonatal deaths) at
42 weeks of gestation is twice that at 40 weeks (4-7 vs 2-3 per 1,000 deliveries, respectively) and
increases 4-fold at 43 weeks and 5- to 7-fold at 44 weeks. 15,16,17 These data also demonstrate that,
when calculated per 1000 ongoing pregnancies, fetal and neonatal mortality rates increase sharply
after 40 weeks.16
Cotzias et al calculated the risk of stillbirth in ongoing pregnancies for each gestational age from 35-43
weeks.17 The risk of stillbirth was 1 in 926 ongoing pregnancies at 40 weeks gestation, 1 in 826 at 41
weeks, 1 in 769 at 42 weeks, and 1 in 633 at 43 weeks. Uteroplacental insufficiency, asphyxia (with
and without meconium), intrauterine infection, and anencephaly all contribute to excess perinatal
deaths, although postterm anencephaly is essentially nonexistent with modern obstetrical care. 34
A number of key morbidities are greater in infants born to postterm pregnancies as well as pregnancies
that progress to and beyond 41 0/7 weeks gestation including meconium and meconium aspiration,
neonatal academia, low Apgar scores, macrosomia, and, in turn, birth injury. For example, since
postterm infants are larger than term infants, with a higher incidence of fetal macrosomia (defined as
estimated fetal weight >4,500 g)35 , they are, in turn, at greater risk for other complications.36,37 Such
complications associated with fetal macrosomia include prolonged labor, cephalopelvic disproportion,
and shoulder dystocia with resultant risks of orthopedic or neurologic injury.

Approximately 20% of postterm fetuses have fetal dysmaturity (postmaturity) syndrome, which
describes infants with characteristics of chronic intrauterine growth restriction from uteroplacental
insufficiency.38 These pregnancies are at increased risk of umbilical cord compression from
oligohydramnios, nonreassuring fetal antepartum or intrapartum assessment, intrauterine passage of
meconium, and short-term neonatal complications (such as hypoglycemia, seizures, and respiratory
insufficiency).
Meconium aspiration syndrome refers to respiratory compromise with tachypnea, cyanosis, and
reduced pulmonary compliance in newborns exposed to meconium in utero and is seen in higher rates
in postterm neonates.39 Indeed, the 4-fold decrease in the incidence of the meconium aspiration
syndrome in the United States from 1990-1998 has been attributed primarily to a reduction in the
postterm delivery rate21 with very little contribution from conventional interventions designed to protect
the lungs from the chemical pneumonitis caused by chronic meconium exposure, such as
amnioinfusion40,41 or routine nasopharyngeal suctioning of meconium-stained neonates. 42
Postterm pregnancy is also an independent risk factor for neonatal encephalopathy 43 and for death in
the first year of life.16,17
While much of the work above has been conducted in postterm pregnancies. Some of the fetal risks
such as presence of meconium, increased risk of neonatal academia, and even stillbirth have been
described as being greater at 41 weeks of gestation and even at 40 weeks of gestation as compared
with 39 weeks gestation.22,23 For example, in one study, the rates of meconium and neonatal academia
both increased throughout term pregnancies beyond 38 weeks of gestation. In addition to stillbirth
being increased prior to 42 weeks of gestation, one study found that the risk of neonatal mortality also
increases beyond 41 weeks of gestation.44 Thus, 42 weeks does not represent a threshold below which
risk is uniformly distributed. Indeed, neonatal morbidity (including meconium aspiration syndrome, birth
injury, and neonatal acidemia) appears to be the lowest at around 38 weeks and increase in a
continuous fashion thereafter.45
Maternal risks and mode of delivery
The maternal risks of postterm pregnancy are often underappreciated. These include an increase in
labor dystocia (9-12% vs 2-7% at term), an increase in severe perineal injury (3 rd and 4th degree
perineal lacerations) related to macrosomia (3.3% vs 2.6% at term) and operative vaginal delivery, and
a doubling in the rate of cesarean delivery (14% vs 7% at term). 18,27,28,29 The latter is associated with
higher risks of complications such as endometritis, hemorrhage, and thromboembolic disease. 28,46
In addition to the medical risks, the emotional impact (anxiety and frustration) of carrying a pregnancy
1-2 weeks beyond the estimated due date should not be underestimated. In a randomized, controlled
trial of women at 41 weeks of gestation, women who were induced would desire the same
management 74% of the time, whereas women with serial antenatal monitoring only desired the same
management 38% of the time.47
Similar to neonatal outcomes, maternal morbidity also increases in term pregnancies prior to 42 weeks
of gestation. Such complications as chorioamnionitis, severe perineal lacerations, cesarean delivery
rates, postpartum hemorrhage, and endomyometritis all increase progressively after 39 weeks
of gestation.23,30,31,32,21

Timing of Delivery
The first decision that must be made when managing an impending postterm pregnancy is whether to
deliver. In certain cases (eg, nonreassuring surveillance, oligohydramnios, growth restriction, certain
maternal diseases), the decision is straightforward. In these high-risk situations, the time at which the
risks of remaining pregnant begin to outweigh the risks of delivery may come at an earlier gestational
age (eg, 39 weeks of gestation). However, frequently several options can be considered when
determining a course of action in the low-risk pregnancy. The certainty of gestational age, cervical
examination findings, estimated fetal weight, patient preference, and past obstetric history must all be
considered when mapping a course of action.
The main argument against a policy of routine induction of labor at 41 0/7 to 41 6/7 weeks has been
that induction increases the rate of cesarean delivery without decreasing maternal and/or neonatal
morbidity. Some of the studies that failed to show a reduction in fetal/neonatal morbidity were diluted
by poorly dated pregnancies that were not necessarily postterm. In addition, the potential for

increasing the risk for cesarean delivery with a failed induction is far less likely in the era of safe and
effective cervical ripening agents.
To date, more than 10 studies have been published of elective induction of labor, many of them at 41
weeks of gestation.48,34,49,50,51,52 The preponderance of the evidence from these studies, including metaanalyses, find that not only is rate of cesarean delivery not increased in women who were randomized
to routine induction of labor, but also more cesarean deliveries were performed in the noninduction
groups, and the most frequent indication was fetal distress. Even with multiple studies, very few
neonatal differences have been demonstrated. However, the reduction in meconium is statistically
significant and the rate of neonatal mortality is lower.
In summary, routine induction at 41 weeks of gestation does not increase the cesarean delivery rate
and may decrease it without negatively affecting perinatal morbidity or mortality. In fact, both the
woman and the neonate benefit from a policy of routine induction of labor in well-dated, low-risk
pregnancies at 41 weeks' gestation. A policy of routine induction at 40 weeks' has few benefits, and
there are multiple reasons not to allow a pregnancy to progress beyond 42 weeks.
Prior to 41 weeks of gestation, the evidence becomes more scant with only 3 small, non-US,
randomized, controlled trials comparing elective induction of labor to expectant management of
pregnancy.51 However, elective induction of labor is increasingly being used as a management
strategy.53,54 While this management may be reasonable in a practice that allows 48 hours or more for
the management of the latent phase and the first stage of labor overall, in a setting where induction of
labor is called a failure after 18-24 hours, it will likely further increase the cesarean delivery rate.

Prevention of Postterm Pregnancy


As noted above, the most decisive way to prevent postterm pregnancy is induction of labor prior to 42
weeks gestation. However, since complications rise during 40 and 41 weeks' gestation and both
clinicians and patients are concerned about the risks of induction of labor, it is perceivably better for
women to go into spontaneous labor at 39 weeks of gestation on their own. Several minimally invasive
interventions have been recommended to encourage the onset of labor at term and prevent postterm
pregnancy, including membrane stripping, unprotected coitus, and acupuncture.
Stripping or sweeping of the fetal membranes refers to digital separation of the membranes from the
wall of the cervix and lower uterine segment. This technique, which likely acts by releasing
endogenous prostaglandins from the cervix, requires the cervix to be sufficiently dilated to admit the
practitioners finger. Although stripping of the membranes may be able to reduce the interval to
spontaneous onset of labor, a reduction in operative vaginal delivery, cesarean delivery rates, or
maternal or neonatal morbidity has not been consistently proven. 55,56,57
Unprotected sexual intercourse causes uterine contractions through the action of prostaglandins in
semen and potentially release of endogenous prostaglandins similar to stripping of the membranes.
Indeed, prostaglandins were originally isolated from extract of prostate and seminal vesicle glands,
hence their name. Despite some conflicting data, it appears that unprotected coitus may lead to the
earlier onset of labor, reduction in postterm pregnancy rates, and less induction of labor.58,59,60
In a small randomized trial that attempted to address this question, women were randomized to a
group advised to have coitus versus a control group that was not. In this study, the women advised to
have coitus did so more often (60% vs 40%), the difference in the rate of spontaneous labor was not
measurable in this underpowered study.61 Similarly, the efficacy of acupuncture for induction of labor
cannot be definitively assessed because of the paucity of trial data; this requires further
examination.62,63

Cervical Ripening and Intrapartum Management


Once the decision to deliver a patient has been made, the management of the labor induction depends
on the clinical setting, and a brief review of cervical ripening agents and potential complications of
induction of labor is appropriate. A comprehensive review of all available methods for cervical ripening,
indications, contraindications, and dosing is beyond the scope of this article.
As many as 80% of patients who reach 42 weeks' gestation have an unfavorable cervical examination
(ie, Bishop Score <7). Many options are available for cervical ripening. The different preparations,
indications, contraindications, and multiple dosing regimes of each require practitioners to familiarize
themselves with several of the preparations.
Prostaglandin E2 gel and suppositories for vaginal application were used extensively until the late
1990s when many pharmacies stopped manufacturing them because of the advent of commercially

available and less labor-intensive preparations. Currently available chemical preparations include
prostaglandin E1 tablets for oral or vaginal use (misoprostol), prostaglandin E2 gel for intracervical
application (dinoprostone cervical [Prepidil]), and a prostaglandin E2 vaginal insert (dinoprostone
[Cervidil]). Cervidil contains 10 mg of dinoprostone and has a lower constant release of medication
than Prepidil. In addition, this vaginal insert device allows for easier removal in the event of uterine
hyperstimulation.
Many studies have compared the efficacy and risks of various prostaglandin cervical ripening agents.
Rozenburg et al performed a randomized trial comparing intravaginal misoprostol and dinoprostone
vaginal insert in pregnancies at high risk of fetal distress. They found that both methods were equally
safe for the induction of labor and misoprostol was actually more effective. 64
Another method for ripening the cervix is by mechanical dilation. These devices may act by a
combination of mechanical forces and by causing release of endogenous prostaglandins. Foley
balloon catheters placed in the cervix, extra-amniotic saline infusions, and laminaria have all been
studied and have been shown to be effective.
Regardless of what method is chosen for cervical ripening, the practitioner must be aware of the
potential hazards surrounding the use of these agents in the patient with a scarred uterus. In addition,
the potential for uterine tachysystole and subsequent fetal distress requires that care be taken to avoid
using too high a dose or too short a dosing interval in an attempt to get a patient delivered rapidly.
Care should also be taken when using combinations of mechanical and pharmacologic methods of
cervical ripening.
Once an induction of labor has begun, watch for the major potential complications associated with
inductions beyond 41 weeks' gestation and have a plan for dealing with each. Complications include
the presence of meconium, macrosomia, and fetal intolerance to labor.
The further the pregnancy progresses beyond 40 weeks, the more likely it is that significant amounts
of meconium will be present. This is due to increased uteroplacental insufficiency, which leads to
hypoxia in labor and activation of the vagal system. In addition, the presence of a smaller amount of
amniotic fluid increases the relative concentration of meconium in utero.
Traditionally, saline amnioinfusion and aggressive nasopharyngeal and oropharyngeal suctioning at
the perineum were used to decrease the risk of meconium aspiration syndrome. Recent studies
contradict this standard practice. Fraser et al performed a prospective, randomized, multicenter study
evaluating the risks and benefits of amnioinfusion for the prevention of meconium aspiration
syndrome.41 They concluded that in clinical settings, which have peripartum surveillance, amnioinfusion
of thick meconium-stained amniotic fluid did not decrease the risk of moderate-to-severe meconium
aspiration syndrome, perinatal death, or other serious neonatal disorders compared with expectant
management. In addition, other recent studies have shown that deep suctioning of the airway at the
perineum does not effectively prevent meconium aspiration syndrome, contrary to popular belief.
Fetal macrosomia can lead to maternal and fetal birth trauma and to arrest of both first- and secondstage labor. Because the risk of macrosomia increases throughout term and postterm pregnancies,
one of the most important parts of the delivery plan is being prepared for shoulder dystocia in the
event that this unpredictable, anxiety-provoking, and potentially dangerous condition arises. To
prepare such an event, experienced clinicians should be present at the delivery, a stool/step next to
the delivery bed should be placed to help with suprapubic pressure, and the maneuvers to reduce the
shoulder dystocia should be reviewed.
Finally, intrapartum fetal surveillance in an attempt to document fetal intolerance to labor before it
leads to acidosis is critical. Whether continuous fetal monitoring or intermittent auscultation is used,
interpretation of the results by a well-trained clinician is of paramount importance. If the fetal heart rate
tracing is equivocal, fetal scalp stimulation and/or fetal scalp blood sampling may provide the
reassurance necessary to justify continuing the induction of labor. If the practitioner cannot find
reassurance that the fetus is tolerating labor, cesarean delivery is recommended.

Antepartum Fetal Surveillance


Antepartum fetal surveillance is suggested in postterm pregnancies when delivery is not performed.
Although no randomized prospective trials demonstrate a benefit of fetal monitoring, no proof exists
that it negatively affects postterm pregnancies either. Despite a lack of evidence, antepartum fetal
surveillance of postterm pregnancies has become an accepted standard of care despite a lack of
consensus as to a specific regimen of surveillance to be offered. 1
The perinatal mortality rate increases gradually throughout pregnancy, with the greatest risk affecting
pregnancies continuing past 41 weeks. Therefore, although no evidence can prove that routine
monitoring between 40 and 42 weeks improves perinatal outcome, ACOG states that it is reasonable

to begin antepartum testing after 41 weeks' gestation. 1 In one study of this issue, Bochner et al
demonstrated that initiating monitoring at 41 weeks of gestation led to lower rates of complications. 65
No single method of antenatal surveillance has been shown to be superior to any other. Options
include a nonstress test, contraction stress test, full biophysical profile, modified biophysical profile
(nonstress test and amniotic fluid index), or a combination of these modalities. Evaluation of the
amniotic fluid level has been shown to be especially important because of demonstrated increased
adverse pregnancy outcomes. Therefore, delivery should be implemented in the event of
oligohydramnios with or without other nonreassuring tests. Doppler ultrasonography has been shown
to provide no proven advantage for evaluating postdate or postterm pregnancies and should not be
routinely used.66,67
A modified biophysical profile has been shown to be as sensitive as a full biophysical profile. Boehm et
al demonstrated that twice-weekly testing of patients at risk for fetal distress was superior to weekly
testing, decreasing the rate of stillbirth from 6.1 per 1000 live births to 1.9 per 1000.
In summary, the use of a nonstress test and an amniotic fluid index 2 times per week for pregnancies
continuing past 41 weeks is reasonable. In addition, if any indication during antepartum surveillance
leads the practitioner to question the intrauterine environment, delivery should be expedited.

Summary
The management of postterm pregnancies is complicated and fraught with complex issues. The
decision of whether to induce labor or to proceed with expectant management with or without
antepartum fetal surveillance is not taken lightly. Data support inducing labor at 41 weeks' gestation in
an accurately dated, low-risk pregnancy, regardless of cervical examination findings. This strategy,
although not without its critics, averts the need for antepartum fetal surveillance and does not increase
the cesarean delivery rate; in fact, it may decrease the cesarean delivery rate.

Incidence of postterm pregnancy


The estimated due dateSometimes abbreviated to EDD, or referred to
as the Estimated Date of Delivery. The EDD is calculated as 280 days
after the first day of the last menstrual period.
Visit our comprehensive glossary for more pregnancy terms and
definitions. is a statistical average. In reality, only five percent (1 in 20)
babies are born on their due dates. Forty percent (2 in 5) babies are
born during week forty one or later. About ten to twenty five percent (2
- 5 in 20) of them are born after week forty one. Twelve percent (3 in
25) hold out till week forty three or later, with the final three percent (1
in 30) hanging in till week forty four.
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As the pregnancy continues the baby often continues to grow. About


twenty percent (1 in 5) babies will grow to nine or more pounds at
delivery, with an increased incidence of cesarean section because they
are unable to pass through the birth canalThe passage through which
the baby passes during delivery from the inlet of the true pelvis to the
vaginal orifice.
Visit our comprehensive glossary for more pregnancy terms and
definitions.. Three percent (1 in 33) babies will continue to grow until
they weigh ten pounds or more at delivery!

Risk factors for postterm pregnancy

The cause of postterm pregnancy is still unknown but while there


are many theories, researchers have discovered that if you have a
history of postterm pregnancy, there is a fifty percent chance of
recurrence.

Placental insufficiency
By the end of your pregnancy, the placenta has grown to the size of a
dinner plate, one inch (2.5cm) thick. Looking like a piece of raw liver,
the side that is attached to the uterus is divided into wedges called
cotyledons.
There is a misconception that the placenta ages during pregnancy. In
fact the organ is tremendously resilient, and has the ability to repair
damage resulting from insufficient oxygen, or ischemia. As the
pregnancy progresses, the different components of the placenta simply
change their appearance.
By week thirty six, calcium deposits begin to appear on the surface of
the villi, limiting the exchange of nutrients and waste between the
mother and baby. But this is balanced until term by the proximity of the
fetal blood vessels and the villi themselves. After week forty two, the
placenta will slowly start to lose its efficiency, and no longer be able to
supply the baby with nutrients and support. Your doctor will monitor
the health of your baby as it continues past term, and if there are signs
of fetal distressA condition, usually discovered in labor, in which the
fetal heartbeat follows an abnormal pattern. The fetal heartbeat is
recorded using electronic fetal monitoring.
The acid balance of the fetal blood is measured, and labor is allowed to
continue if it falls within prescribed ranges, and the abnormal
heartbeat does not recur or persist.
If nescessary, attempts will be made to stabilize the fetus by
administering oxygen to the mother, increasing her fluid intake or
prescribing an agent to help the uterus relax. In some cases a cesarean
section may be required.
Visit our comprehensive glossary for more pregnancy terms and
definitions., labor will be induced.

Placental insufficiency and your baby


Most babies remain healthy in the uterus beyond week forty two.
Placental insufficiency affects only twenty percent (1 in 5) postterm
babies, resulting in signs of fetal distressA condition, usually
discovered in labor, in which the fetal heartbeat follows an abnormal
pattern. The fetal heartbeat is recorded using electronic fetal

monitoring.
The acid balance of the fetal blood is measured, and labor is allowed to
continue if it falls within prescribed ranges, and the abnormal
heartbeat does not recur or persist.
If nescessary, attempts will be made to stabilize the fetus by
administering oxygen to the mother, increasing her fluid intake or
prescribing an agent to help the uterus relax. In some cases a cesarean
section may be required.
Visit our comprehensive glossary for more pregnancy terms and
definitions., reduced amniotic fluidThe liquid, which is produced by
both the fetal membranes and the fetus that surrounds the baby
during pregnancy. The liter of fluid at term serves to protect the fetus
during pregnancy and also provide active chemical exchange.
The amniotic fluid consists of maternal and fetal plasma in varying
concentrations. The pH of the fluid is almost neutral and clear,
although lipids and desquamated fetal cells can make it cloudy.
Visit our comprehensive glossary for more pregnancy terms and
definitions., weight loss and meconiumWaste material that collects in
the intestinal tract of the unborn fetus. It is thick and sticky in
consistency and varys in color from dark green to black.
It is formed from a variety of substances from amniotic fluid to
secretions in the intestinal tracts. The presence of meconium in the
amniotic fluid is usually a sign of fetal distress.
After birth the color and consistency of the stool changes with the
ingestion of breast milk or formula.
Visit our comprehensive glossary for more pregnancy terms and
definitions. aspiration.
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MeconiumWaste material that collects in the intestinal tract of the


unborn fetus. It is thick and sticky in consistency and varys in color
from dark green to black.
It is formed from a variety of substances from amniotic fluid to
secretions in the intestinal tracts. The presence of meconium in the
amniotic fluid is usually a sign of fetal distress.
After birth the color and consistency of the stool changes with the
ingestion of breast milk or formula.
Visit our comprehensive glossary for more pregnancy terms and
definitions. aspiration occurs in fifteen percent (1 in 6) pregnancies by
week forty. It is a sign of fetal distressA condition, usually discovered in
labor, in which the fetal heartbeat follows an abnormal pattern. The
fetal heartbeat is recorded using electronic fetal monitoring.
The acid balance of the fetal blood is measured, and labor is allowed to
continue if it falls within prescribed ranges, and the abnormal
heartbeat does not recur or persist.

If nescessary, attempts will be made to stabilize the fetus by


administering oxygen to the mother, increasing her fluid intake or
prescribing an agent to help the uterus relax. In some cases a cesarean
section may be required.
Visit our comprehensive glossary for more pregnancy terms and
definitions., especially if it is thick and there is little amniotic fluidThe
liquid, which is produced by both the fetal membranes and the fetus
that surrounds the baby during pregnancy. The liter of fluid at term
serves to protect the fetus during pregnancy and also provide active
chemical exchange.
The amniotic fluid consists of maternal and fetal plasma in varying
concentrations. The pH of the fluid is almost neutral and clear,
although lipids and desquamated fetal cells can make it cloudy.
Visit our comprehensive glossary for more pregnancy terms and
definitions.. Your doctor will use internal fetal monitoring to determine
whether the baby is in distress.
Postmature babies lose all their body fat, leaving their skin red and
wrinkled. By week forty three the risk of stillbirth doubles, and they are
five times safer outside the uterus. The following week the risk of
stillbirth has tripled, and the risk of remaining in the uterus is seven
times greater than delivery. Your doctor will seriously consider the
possibility of inducing the baby by this stage of the pregnancy.

Managing postterm pregnancy


If this is your first pregnancy and you baby has not engagedThe term
used to describe the final portion of pregnancy during which the baby's
head (or other presenting part) has settled into the pelvic cavity.
Visit our comprehensive glossary for more pregnancy terms and
definitions. in the two weeks following your due date, your doctor will
become concerned about cephalopelvic disporportionA condition in
which the size of the baby's head is markedly larger than the size of
the maternal birth canal. In some instances it is possible for the baby
to be born vaginally although the most usual and safest course of
action is delivery by cesarean section.
Visit our comprehensive glossary for more pregnancy terms and
definitions.. To make sure that the baby's head will pass safely through
the birth canalThe passage through which the baby passes during
delivery from the inlet of the true pelvis to the vaginal orifice.
Visit our comprehensive glossary for more pregnancy terms and
definitions., your doctor will ask you to lie on your back. This will allow
the doctor to feel the head of the baby resting at the brim of the pelvis.
You will then be asked to prop yourself on your elbows. If your baby's
head slips into the pelvis there is no risk of cephalopelvic

disporportionA condition in which the size of the baby's head is


markedly larger than the size of the maternal birth canal. In some
instances it is possible for the baby to be born vaginally although the
most usual and safest course of action is delivery by cesarean section.
Visit our comprehensive glossary for more pregnancy terms and
definitions..
For this reason many pregnancies are induced after week forty two. As
your pregnancy continues past term, your doctor will use the nonstress
test, contraction stress test, nipple stimulation test and biophysical
profile to monitor the baby to ensure that it is healthy and active.
Ultrasound may also be used to make sure that your baby is healthy
and active. But if testing shows that the baby is healthy and vigorous
(no signs of post maturity) then your doctor may wait until labor begins
naturally. A family history of longer than average gestation will
reassure your doctor that your pregnancy is safe, and can continue
while being closely monitored.

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Labor & Delivery


Stages of labor
Medicinal pain relief
Natural pain relief
Birth partner's roles
Special procedures
Delivery complications
o Breech presentation
o Placental abruption
o Placenta accreta
o Placenta previa
o Preeclampsia (HELLP syndrome)
o Premature labor
o Premature rupture of membranes (PROM)
o Postterm pregnancy
o Shoulder dystocia

To define abnormal labor, a definition of normal labor must be understood and accepted.
Normal labor is defined as uterine contractions that result in progressive dilation and
effacement of the cervix. Any deviation from normal labour is called abnormal
labour.
An abnormal labor may be referred to as dystocia, which simply means difficult labor or
childbirth.

Malpresentation
Malpresentation refers to a fetal presenting part other than the vertex and includes
breech, transverse, compound, shoulder, face, and brow presentation. Or
malpresentations are those in which the baby's head does not present at the cervix first.
Malpresentation is where the baby is in a difficult position for the birth process.. It may
be identified late in pregnancy or may not be discovered until the initial assessment
during labour.
Signs Suggestive of Malpresentations

Pendulous abdomen.
Nonengagement of the presenting part in the last 3-4 weeks in primigravida.

Premature rupture of membranes or its rupture early in labour.


Delay in the descent of the presenting part during labour.
Vaginal examination, X-ray or ultrasonography are more conclusive

Malposition
Fetal malposition refers to a position other than an occipitoanterior position.malpositions
include occipitotransverse, occipitoposterior, and obliqueor acnclytic positions of the
fetal head in relation to the maternal pelvis. Fetal malpositions are assessed during
labour. .
Malpositions, in contrast, all present with the head down BUT may not be situated in
the way that is most optimal for birth. The head may be tilted to one side, the baby may
face towards the mother's tummy instead of towards her back, the baby's chin may not
be tucked under, or the baby may have a hand/arm up by its head.
Malpresentation and malposition may increase the duration of labor, may pose risks to
maternal-fetal well-being and may necessitate operative vaginal delivery, cesarean
section, or other interventions to accomplish delivery.
Causes of Malpresentations and Malpositions

Defects in the powers:


o Pendulous abdomen: laxity of the abdominal muscles.
o Dextro-rotation of the uterus: rotation of the uterus in anti-clock wise
favours occipito-posterior in right occipito-anterior position.
Defects in the passages:
o Contracted pelvis/CPD
o Android pelvis.
o Pelvic tumours.
o Uterine anomalies as bicornuate, septate or fibroid uterus.
o Placenta praevia.
o Pelvic fractures
Defects in the passenger:
o Preterm foetus.
o Intrauterine foetal death.
o Macrosomia.
o Multiple pregnancy.
o Congenital anomalies as anencephaly and hydrocephalus.
o Polyhydramnios.
o Coils of the cord around the neck favours face presentation.

Complications of Malpresentations and Malpositions

Premature rupture of membranes or its rupture early in labour.


Cord presentation and prolapse.
Prolonged labour due to hypotonic or hypertonic inertia.
Obstructed labour with higher incidence of rupture uterus.
Increased incidence of instrumental and operative delivery.
Increased incidence of trauma to the genital tract.
Increased incidence of postpartum haemorrhage and puerperal infection.
Increased incidence of perinatal mortality.

OCCIPITO-POSTERIOR POSITION
Definition

It is a vertex presentation with foetal back directed posteriorly or A cephalic presentation of


the fetus with the occiput turned toward either the right or left rear quarter of the mother's pelvis.

These positions occur in approximately 10% of labour. This is the most common
malposition. The head is usually incompletely flexed and the occipitofrontal diameter
presents - ie a larger diameter is involved.
Posterior: baby is head-down and 'looking' at the mothers tummy; its spine is against the
mothers spine. The diameter of the head that must fit through first is larger, and many
posterior babies have their heads de-flexed (chins not tucked under, or 'military position'),
which creates an even larger diameter. This often makes for a much more difficult, slow,
and painful birth. Although some posterior babies can be born vaginally if they are
smaller and/or have their chins well-tucked under, a large percentage of posterior babies
result in c-section due to a "Cephalo-Pelvic Disproportion" diagnosis (CPD, or baby 'too
big' for mother's pelvis in that position) or a "Failure to Progress" diagnosis (labor stalls
out partway through dilation because of unequal or inadequate pressure on the cervix
from baby's position). A posterior position can often be turned to anterior through the use
of special exercises/positions before or during labor, some turn on their own, and a few
providers also know how to go in and turn the baby manually during labor. Once they turn, these babies
usually are born very quickly.

Right occipito-posterior (ROP) is more common than left occipito-posterior (LOP)


because:

The left oblique diameter is reduced by the presence of sigmoid colon.


The right oblique diameter is slightly longer than the left one.
Dextro-rotation of the uterus favours occipito-posterior in right occipito-anterior
position.

Aetiology

The shape of the pelvis: anthropoid and android pelvises are the most common
cause of occipito-posterior due to narrow fore-pelvis.

Maternal kyphosis: The convexity of the foetal back fits with the concavity of the
lumbar kyphosis.
Anterior insertion of the placenta: the foetus usually faces the placenta (doubtful).
Other causes of malpresentations: as
o placenta praevia,
o pelvic tumours,
o pendulous abdomen,
o polyhydramnios,
o multiple pregnancy.

Diagnosis
During pregnancy

Inspection:
o The abdomen looks flattened below the umbilicus due to absence of round
contour of the foetal back.
o A groove may be seen below the umbilicus corresponding to the neck.
o Foetal movement may be detected near the middle line.
Palpation:
o Fundal grip:
The breech is felt as a soft, bulky, irregular non-ballotable mass.
o Umbilical grip:
The back felt with difficulty in the flank away from the middle
line.
The anterior shoulder is at least 3 inches from the middle line.
The limbs are easily felt near, or on both sides, of the middle line.
o First pelvic grip:
The head is usually not engaged due to deflexion.
The head is felt smaller and escapes easily from the palpating
fingers as they catch the bitemporal diameter instead of the
biparietal diameter in occipito-anterior.
o Second pelvic grip:
The head is usually deflexed.
Auscultation:
o FHS are heard in the flank away from the middle line.
o In major degree of deflexion, the FHS may be heard in middle line.
Ultrasonography or lateral view x-ray.

During labour

In addition to the previous findings vaginal examination reveals:

The direction of the occiput.


The degree of deflexion.

Mechanism of Labour

A certain degree of deflexion is present due to:

Opposition of the two convexities of the foetal and maternal spines prevents
flexion and promotes deflexion.
The longer biparietal diameter (9.5cm) enters the narrow sacro-cotyloid diameter
(9cm) while the shorter bitemporal diameter (8cm) enters the longer oblique
diameter (12cm).

As a result of deflexion, the occipito-frontal diameter 11.5 cm enters the pelvis leading to
delayed engagement.
Taking in consideration the rule that the part of the foetus that meets the pelvic floor first
will rotate anteriorly, the degree of deflexion determines the mechanism of labour as
follow:
Normal mechanism (90%)

Deflexion is corrected and complete flexion occurs. The occiput meets the pelvic floor
first, long anterior rotation 3/8 circle occurs bringing the occiput anteriorly and the foetus
is delivered normally.
Abnormal mechanism (10%)

Deep transverse arrest (1%):


o In mild deflexion, the occiput rotates 1/8 circle anteriorly and the head is
arrested in the transverse diameter.
Persistent occipito-posterior (3%):
o In moderate deflexion, the occiput and sinciput meet the pelvic floor
simultaneously, no internal rotation and the head persists in the oblique
diameter.
Direct occipito-posterior (face to bubis) (6%):
o In marked deflexion, the sinciput meets the pelvic floor first, rotates 1/8
circle anteriorly and the occiput becomes direct posterior.
In deep transverse arrest and persistent occipito-posterior no
further progress occurs and labour is obstructed as the head cannot
be delivered spontaneously.
In direct occipito-posterior, the head can be delivered by flexion
supposing that the uterine contractions are strong and there is no
contracted pelvis. However, perineal lacerations are more liable to
occur as:
the vulva is distended by the large occipito-frontal diameter
11.5 cm,
the perineum is overstretched by the large occiput.

Factors favour long anterior rotation

Well flexed head


Good uterine contractions.
Roomy pelvis.
Good pelvic floor.
No premature rupture of membranes.

Causes of failure of long anterior rotation

Deflexed head.
Uterine inertia.
Contracted pelvis: rotation of the head cannot easily occur in android pelvis due
to projection of the ischial spines and convergence of the side walls.
Lax or rigid pelvic floor.
Premature rupture of membranes or its rupture early in labour.

Management of Labour
First stage

Exclude contracted pelvis.


Exclude presentation or prolapse of the cord.
Inertia and prolonged labour are expected so oxytocin may be indicated unless
there is contraindication.
Contractions are sustained, irregular and accompanied by marked backache which
needs analgesia as pethidine or epidural analgesia.
Avoid premature rupture of membranes by:o rest in bed,
o no straining,
o avoid high enema,
o minimise vaginal examinations.
The other management and observations as in normal labour.

Second stage

Wait for 60-90 minutes.


During this period:
o Observe the mother and foetus carefully.
o Combat inertia by oxytocin unless it is contraindicated.
Contraindications of oxytocins:
o Disproportion.
o Incoordinate uterine action.
o Uterine scar e.g. previous C.S, hysterotomy, myomectomy, metroplasty or
previous perforation.
o Grand multipara.
o Foetal distress.
One of the following will occur:

Long internal rotation 3/8 circle:


occurs in about 90% of cases and delivery is completed as in
normal labour.
Direct occipito-posterior (face to pubis):
occurs in about 6% of cases.
the head can be delivered spontaneously or by aid of outlet forceps.
Episiotomy is done to avoid perineal laceration.
Deep transverse arrest (1%) and persistent occipito-posterior (3%):
The labour is obstructed and one of the following should be done:
Vacuum extraction (ventouse):
Proper application as near as possible to the occiput
will promote flexion of the head.
Traction will guide the head into the pelvis till it
meets the pelvic floor where it will rotate.
Manual rotation and extraction by forceps:
Under general anaesthesia the following steps are
done:
Disimpaction: the head is grasped bitemporally and
pushed slightly upwards.
Flexion of the head.
Rotation of the occiput anteriorly by the right hand
vaginally aided by,
Rotation of the anterior shoulder
abdominally towards the middle line by the
left hand or an assistant.
Fix the head abdominally by an assistant,
apply forceps and extract it.
Rotation and extraction by a forceps:
Kiellands forceps:
Single application for rotation and extraction
of the head as this forceps has a minimal
pelvic curve.
Bartons forceps:
Originally was designed for deep transverse
arrest.
It has a hinge in one blade between the blade
proper and shank to facilitate application.
The axis of the handle to that of the blades is
55o i.e. the angle of the pelvic inlet to the
outlet.
It is used for rotation only then conventional
forceps is applied for extraction unless it has
an axis traction piece so it can be used for
rotation and extraction.
Scanzoni double application:

The conventional forceps is applied to rotate


the occiput anteriorly then the forceps is
removed and reapplied so that the pelvic
curve of the forceps is directed anteriorly
and extract the head.
This method is out of modern obstetrics as it
is hazardous to the mother and foetus.
N.B. The head should be engaged for manual or
forceps rotation to be done.
Caesarean section:
It is indicated in:
Failure of the above methods.
Other indications for C.S. as;
contracted pelvis,
placenta praevia,
prolapsed pulsating cord before full
cervical dilatation, and
elderly primigravida.
Craniotomy:
if the foetus is dead.

Actually speaking, the methods used in modern obstetrics are vacuum extraction and
Caesarean section.

Brow presentation
1. Definition
1. Head hyperextended, with brow as presenting part
2. Pathophysiology
1. Normal Attitude: Fetus is in full flexion
1. Smallest fetal head diameter: Suboccipitobregmatic
2. Brow presentation is an extended attitude
1. Results in largest head diameter: Occipitomental
2. Increases diameter 3 cm (24%) over flexed head
3. May results in Failure to Progress
3. Epidemiology
1. Incidence: 0.02% of singleton deliveries
4. Causes
1. Similar to Face Presentation

5. Signs
1. Digital cervical exam
1. Forehead features palpable (anterior Fontanel, nose)
6. Management
1. Ceserean section required in most cases
2. Brow presentation rarely can deliver vaginally unless:
1. Spontaneously converts to vertex or Face Presentation
2. Fetus is very small or pelvis is very large
3. Do not attempt to convert brow presentation to vertex
4. Never apply vacuum extractor to brow presentation
5. Do not apply internal scalp electrodes
6. Avoid Oxytocin

Compound presentation
1. Definition
1. Hand prolapses alongside fetal head
2. Epidemiology
1. Incidence: 0.04 TO 0.14%
2. More common in prematurity
3. Signs
1. Digital cervical exam
1. Hand palpated beside presenting fetal head
4. Differential Diagnosis
1. Fetal foot beside head
5. Management
1. Expectant management
1. Vaginal Delivery usually occurs
2. Consider repositioning if descent arrested
1. Elevate fetal hand
2. Bring head downward

Occipitoposterior position
1. Definition
1. Abnormal Fetal Position with occiput at maternal sacrum
2. Fetal face towards maternal symphysis pubis
2. Physiology
1. Less favorable fetal head diameter for delivery
1. Deflexion of fetal head
2. Posterior presentation
2. Usually corrects spontaneously

1. Rotates to Occiput Anterior position in 90% of cases


3. Symptoms
1. Back labor
2. Prolonged labor
1. Nulliparous: Additional two hours
2. Multiparous: Additional one hour
4. Signs: Digital cervical exam
1. Asymmetric cervical dilation
1. Persistant anterior lip
2. Palpation of fetal head
1. Fetal anterior Fontanel most palpable
2. Follow sagittal Suture to posterior Fontanel
3. Posterior Fontanel, lambdoid Suture with be posterior
5. Complications
1. Failure to Progress
2. Extended episiotomy or perineal Laceration
6. Management
1. Spontaneous Delivery (anticipate in 45% of cases)
2. Maternal position changes (unclear efficacy)
1. Any position in which mother curls forward from hips
2. Hands and knees
3. Squatting
3. Manual rotation during vaginal exam
1. See Manual Rotation in Occipitoposterior Presentation
4. Vacuum Delivery
1. Place vacuum cup as posterior as possible
1. Inproves flexion of fetal head
2. Do not use vacuum to rotate fetal head
1. Results in scalp Laceration
5. Forceps Delivery
6. Forceps Rotation (skilled clinician only)
1. Techniques: Scanzoni or Kielland
2. Requires immediate Ceserean back-up
3. Rarely performed in U.S. now

Asynclitic: baby is head-down and probably anterior but the head is slightly tilted to one side or
'off' in some way so that the head does not move down into the pelvis smoothly. Usually the side
of the head or 'parietal' bones present first instead of the crown of the head, making the diameter
much larger. There are also exercises that can help resolve this position.
Compound: baby's hand presents alongside its head (sometimes called a 'nuchal hand'), making a
larger size that has to go through the pelvis; many of the same symptoms as other malpositions.
One other variation of this is when the baby's arm or elbow is across its face ('nuchal arm'), which
can cause intense pain. A baby can be born with a nuchal hand alongside its head, although the
process is usually slow. Often however, something happens to make the baby move its hand or
arm back, and then the baby is born very quickly thereafter. Very painful position, but resolves
more easily than some of the others.

Brow or Face: baby is head-down with the head de-flexed and the chin tilted so that either the
forehead (brow) or face is towards the mother's vagina. This is very difficult for vaginal birth
(although a few are on record); most often results in a c-section if the position cannot be fixed.
Oblique: baby is head-down but its whole body is at an angle to the pelvis and cannot enter. If the
position cannot be resolved, usually results in a c-section. [Note: Compound, Brow, Face, and
Oblique are listed as either malpositions or malpresentations, depending on the source.]

Cervical ripening
1.
Medications: Standard
1. Dinoprostone (PGE2 Gel, Cervidil, Prepidil)
2. Misoprostol (PGE1, Cytotec)
2. Procedures: Membrane Stripping (Membrane Sweeping)
1. Benefit
1. Stimulates prostaglandin release
2. Reduces the need for Labor Induction
1. Boulvain (1998) Br J Obstet Gynaecol 105:34
3. Useful as adjunct in Labor Induction
1. Allows for lower overall Oxytocin dose
2. Foong (2000) Obstet Gynecol 96:539
2. Risk
1. Unintentional Rupture of Membranes
2. Infection
3. Bleeding
3. Technique
1. Examining finger inserted into cervix
2. Finger moved in circular fashion inside endocervix
3. Press against internal cervical os
4. Separates membranes from lower uterine segment
3. Procedures: Methods to apply pressure to endocervix
1. General
1. Mechanism: Local pressure releases prostaglandins
2. Risks
1. Infection risk with Laminaria
2. Artificial Rupture of Membranes
3. Abruptio Placenta
4. Cervical or uterine bleeding
2. Hygroscopic Dilator (Laminaria, Lamicel)
1. Dilator swells with absorption of local fluid
2. Preparations
1. Laminaria japonicum (Kelp, natural)
2. Lamicel (synthetic)
3. Technique
1. Outpatient placement of dilator in endocervix

2. Successive dilators placed until endocervix full


3. No Fetal Heart Rate monitoring needed
3. Balloon Dilator (e.g. 16 french Foley Catheter)
1. Technique
1. Catheter placed in endocervix
2. Catheter tip inflated with 30 cc sterile water
3. Traction applied to catheter
4. Start Induction when catheter is extruded
2. Adjuncts
1. Weight end of catheter
2. Tug on catheter 2-4 times per hour
3. Sterile saline infusion
4. Prostaglandin Gel
3. Safety
1. Does not appear to predispose to subsequent PTL
2. Sciscione (2003) Am J Obstet Gynecol 190:751
4. Non-Pharmacologic Methods
1. Breast stimulation
1. See Oxytocin Challenge Test
2. Rigorous trials lacking to show benefit
3. Theoretical benefit
1. Breast stimulation stimulates Oxytocin release
2. Fetal Heart Rate response similar to OCT
4. Technique
1. Gentle massage or warm compresses applied to breast
2. Done for one hour or repeated three times daily
2. Sexual Intercourse
1. Benefits in cervical ripening or induction unclear
2. Theoretical benefit
1. Female orgasm induces uterine contraction
2. Semen contain prostaglandins
3. Acupuncture or TENS unit
1. Proposed for Oxytocin and prostaglandin release
2. No rigorous studies to show benefit
5. Alternative Medications: Herbals
1. General
1. Used by some nurse-midwives in United States
2. Anecdotal use in some cultures as long tradition
3. No current rigorous studies on safety and efficacy
2. Herbals historically used for cervical ripening
1. Evening Primrose Oil
2. Black Haw
3. Black Cohosh
4. Blue Cohosh
5. Red raspberry leaves
3. References

1. McFarlin (1999) J Nurse Midwifery 44:205


6. Disproved Methods that are not recommended
1. Castor oil
2. Hot baths
3. Enemas
7. References
1. Adair (2000) Clin Obstet Gynecol 43:447
2. Tenore (2003) Am Fam Physician 67(10):2123
Prostaglandins
1. Indications
1. Bishop Score <6
2. Membranes intact
3. No active contraction pattern
1. Less than 10 mild contractions per hour
2. Medication: Dinoprostone Gel (PGE2 gel, Prepidil)
1. Initiate Fetal Heart Rate and tocometry
1. Start 15-30 minutes before gel inserted
2. Continue monitoring for 30-120 minutes after
2. Insertion Technique
1. Use one syringe of gel (0.5 mg in 3cc KY)
2. Introduce gel into cervix
1. Cervix not effaced: Use 20 mm catheter
2. Cervix effaced 50% or greater: Use 10 mm catheter
3. Intracervical is preferred over posterior fornix
1. Perry (2004) Obstet Gynecol 103:13
3. Patient remains supine for 30 minutes
3. Dosing
1. Repeat every 6 hours up to 3 doses in 24 hours
4. End points
1. Bishop Score of 8 or greater
2. Strong uterine contractions
5. Drug interactions
1. Wait 6-12 hours before starting Pitocin
3. Medication: Dinoprostone Pessary (PGE2, Cervidil)
1. Releases Dinoprostone at 0.3 mg/hour for 12 hours
2. Insert pessary at cervix
3. Monitor Fetal Heart Tones and tocometry
1. Start 15 to 30 minutes before insertion
2. Continue monitoring for 15 minutes after removal
4. Remain recumbent for 2 hours after insertion
5. Pull pessary out via string if hyper-stimulated
4. Medication: Misoprostol (PGE1, Cytotec)
1. Insert one fourth of 50 mcg tablet intravaginally
1. Avoid use of K-Y or other gel at time of insertion

5.

6.

7.

8.

1. Interferes with gel dissolving


2. Patient remains supine for 30 minutes
3. Monitor Fetal Heart Tones and toco for 3 hours
4. Repeat every 4-6 hours as needed
5. Wait at least 3 hours before Pitocin
2. Cytotec 50 mcg orally may be preferred
1. Effective ripening with lower hyperstimulation risk
2. See Adverse Effects below
3. References
1. Vengalil (1998) Obstet Gynecol 91:774
Medication: Newer agents (experimental)
1. Mifepristone (Mifeprex)
1. Antiprogesterone
2. Relaxin Hormone
Adverse Effects
1. Tachysystole
1. Criteria: >10 contractions in 20 minutes
2. Dinoprostone Tachysystole Incidence: 33%
3. Misoprostol Tachysystole Incidence
1. Intravaginal gel or tablet: 31 to 49%
2. Oral crushed form or tablet: 16 to 22%
2. Hyperstimulation
1. Criteria
1. Exaggerated uterine response (i.e. Tachysystole)
2. Concerning Fetal Heart Rate tracing
1. Late Decelerations
2. Fetal Tachycardia >160 beats per minute
2. Dinoprostone Hyperstimulation Incidence: 17%
3. Misoprostol Hyperstimulation Incidence
1. Intravaginal gel or tablet: 8%
2. Oral crushed form or tablet: 1 to 2%
3. Uterine Rupture in VBAC
1. Risk: 2.5% in Trial of Labor after Cesarean
4. References
1. Crane (2001) Obstet Gynecol 97:926
2. Ravasia (2000) Obstet Gynecol 183:1176
Complications: Hyperstimulation Management
1. Consider Terbutaline SQ
2. Dinoprostone (Cervidil): Remove
3. Misoprostol (Cytotec): Irrigate vagina
1. Use Normal Saline via 100 cc Syringe (no needle)
2. Repeat several times until pill fragments recovered
References
1. Adair (2000) Clin Obstet Gynecol 43:447
2. Crane (2001) Obstet Gynecol 97:926
3. Sanchez-Ramos (1997) Obstet Gynecol 89:633

4. Tenore (2003) Am Fam Physician 67(10):2123

Dinoprostone (C0012472)
The most common and most biologically active of the mammalian
Definition prostaglandins. It exhibits most biological activities characteristic of
(MSH)
prostaglandins and has been used extensively as an oxytocic agent. The
compound also displays a protective effect on the intestinal mucosa.
A synthetic prostaglandin E2 (PGE2) analogue with smooth muscle
contraction inducing property. It has been suggested that PGE2 regulates the
Definition intracellular levels of cyclic 3, 5-adenosine monophosphate (cAMP) by
(NCI)
activating adenylate cyclase and thereby increases cellular membrane calcium
ion transport. By acting directly on the myometrium, dinoprostone induces
uterine and gastrointestinal smooth muscle contractions.
1. Indications
1. Bishop Score <6
2. Membranes intact
3. No active contraction pattern
1. Less than 10 mild contractions per hour
2. Medication: Dinoprostone Gel (PGE2 gel, Prepidil)
1. Initiate Fetal Heart Rate and tocometry
1. Start 15-30 minutes before gel inserted
2. Continue monitoring for 30-120 minutes after
2. Insertion Technique
1. Use one syringe of gel (0.5 mg in 3cc KY)
2. Introduce gel into cervix
1. Cervix not effaced: Use 20 mm catheter
2. Cervix effaced 50% or greater: Use 10 mm catheter
3. Intracervical is preferred over posterior fornix
1. Perry (2004) Obstet Gynecol 103:13
3. Patient remains supine for 30 minutes
3. Dosing
1. Repeat every 6 hours up to 3 doses in 24 hours
4. End points
1. Bishop Score of 8 or greater
2. Strong uterine contractions
5. Drug interactions
1. Wait 6-12 hours before starting Pitocin
3. Medication: Dinoprostone Pessary (PGE2, Cervidil)
1. Releases Dinoprostone at 0.3 mg/hour for 12 hours
2. Insert pessary at cervix
3. Monitor Fetal Heart Tones and tocometry
1. Start 15 to 30 minutes before insertion
2. Continue monitoring for 15 minutes after removal
4. Remain recumbent for 2 hours after insertion
5. Pull pessary out via string if hyper-stimulated

4. Medication: Misoprostol (PGE1, Cytotec)


1. Insert one fourth of 50 mcg tablet intravaginally
1. Avoid use of K-Y or other gel at time of insertion
1. Interferes with gel dissolving
2. Patient remains supine for 30 minutes
3. Monitor Fetal Heart Tones and toco for 3 hours
4. Repeat every 4-6 hours as needed
5. Wait at least 3 hours before Pitocin
2. Cytotec 50 mcg orally may be preferred
1. Effective ripening with lower hyperstimulation risk
2. See Adverse Effects below
3. References
1. Vengalil (1998) Obstet Gynecol 91:774
5. Medication: Newer agents (experimental)
1. Mifepristone (Mifeprex)
1. Antiprogesterone
2. Relaxin Hormone
6. Adverse Effects
1. Tachysystole
1. Criteria: >10 contractions in 20 minutes
2. Dinoprostone Tachysystole Incidence: 33%
3. Misoprostol Tachysystole Incidence
1. Intravaginal gel or tablet: 31 to 49%
2. Oral crushed form or tablet: 16 to 22%
2. Hyperstimulation
1. Criteria
1. Exaggerated uterine response (i.e. Tachysystole)
2. Concerning Fetal Heart Rate tracing
1. Late Decelerations
2. Fetal Tachycardia >160 beats per minute
2. Dinoprostone Hyperstimulation Incidence: 17%
3. Misoprostol Hyperstimulation Incidence
1. Intravaginal gel or tablet: 8%
2. Oral crushed form or tablet: 1 to 2%
3. Uterine Rupture in VBAC
1. Risk: 2.5% in Trial of Labor after Cesarean
4. References
1. Crane (2001) Obstet Gynecol 97:926
2. Ravasia (2000) Obstet Gynecol 183:1176
7. Complications: Hyperstimulation Management
1. Consider Terbutaline SQ
2. Dinoprostone (Cervidil): Remove
3. Misoprostol (Cytotec): Irrigate vagina
1. Use Normal Saline via 100 cc Syringe (no needle)
2. Repeat several times until pill fragments recovered
8. References

1.
2.
3.
4.

Adair (2000) Clin Obstet Gynecol 43:447


Crane (2001) Obstet Gynecol 97:926
Sanchez-Ramos (1997) Obstet Gynecol 89:633
Tenore (2003) Am Fam Physician 67(10):2123

Dinoprostone (C0012472)
The most common and most biologically active of the mammalian
Definition prostaglandins. It exhibits most biological activities characteristic of
(MSH)
prostaglandins and has been used extensively as an oxytocic agent. The
compound also displays a protective effect on the intestinal mucosa.
A synthetic prostaglandin E2 (PGE2) analogue with smooth muscle
contraction inducing property. It has been suggested that PGE2 regulates the
Definition intracellular levels of cyclic 3, 5-adenosine monophosphate (cAMP) by
(NCI)
activating adenylate cyclase and thereby increases cellular membrane calcium
ion transport. By acting directly on the myometrium, dinoprostone induces
uterine and gastrointestinal smooth muscle contractions.