POST TERM PREGNANCY

Definition
Literal meaning of prolonged pregnancy or post term
pregnancy is any pregnancy which has passed beyond
the expected date of delivery. But for clinical, post
term pregnancy is as a pregnancy equal to or more
than 42 completed weeks from the first day of the last
menstrual period.

Incidence
The incidence is varies from 2-10% because
different criteria in definition. According to
retrospective study of delivery beyond 290 days
the incidence is low as 2 %. Based on delivery
beyond 42 weeks, the incidence come 10%. When
an early ultrasound scan is used the incidence is
reduced from 10% to 3% . (Hovi et al 2006)

Causes

The causes of post term pregnancy is unknown.

1. Previous post mature birth.
2. Irregular menstrual cycle.
3. Primi gravida
4. Elderly pregnancy
5. High socioeconomic status
6. Sendentary life style
7. Anencephaly without polyhydramnious

9. Male fetus (placental sulphatase deficiency)

10.Fetal adrenal hypoplasia
Symptoms of post mature baby:
Different babies will show different symptoms of
postmaturity. Some postmature babies will show no or little
sign of postmaturity. The most common symptoms are:
-. Dry skin
-. Overgrowth nails
-. Creases on the babys palms and soles of their feet.
-. Minimal fat
-. A lot hair on their head
-. A brown, green or yellow discoloration of their skin

Diagnosis
1.Last menstrual period (LMP) : if mother is sure about
her date of menstrual cycle, it is fairly reliable diagnostic
aid in calculation of EDD. In case of mistakem pregnancy
can be occur any time like lactational amenorrhoea period
or withdrawl of pill which make confusion.
2. From date of quickening: normal quickening occurs
between 18-20 weeks pregnancy.
3. Fundal height

4. Suspected clinical findings: weight loss, girth of the

abdomen gradually diminishes because of diminishing
liquor volume, history of false pain, fundal height, fetal part
can be palpable on abdominal palpation, cervical ripening
on internal examination.
5. Investigations:
- Ultrasound
- X-ray abdomen
-Amniocentesis:- biochemical and cytological
may help in assessment of maturity.

paramiters

Risk or Complications of Post- term Pregnancy

Maternal effects
i.

Incidence cesarean section rate is double.

ii. Increased incidence of induction of labor, instrumental

delivery
iii. Risk of birth canal trauma and postpartum hemorrhage
iv. Prolonged labor or CPD due to large and mature skull
v.

Increased anxiety and fear

Fetal effects
i.

Chances of fetal hypoxia due to placental insufficiency during

pregnancy.

ii. IUGR 20%

iii. Larger than date of prenancy
iv. Fetal death may occur
v.

Decreased liquor volume

vi. Increased risk of asphyxia and intracranial damage during labor

vii. Muconium aspiration syndrome and atelectasis due to
intrauterine anoxia and inhalation of meconium
viii. Hypoglycemia and polycythemia in IUGR post term babies
ix. Increased perinatal and neonatal mortality and morbidity due to
low APGAR score.

Management of Post-term Pregnancy

Management of prolonged pregnancy must include an
accurate dating

of the pregnancy to determine the

pregnancy is prolonged for that individual. The management

is depend on complicated or uncomplicated pregnancy.
1. Mother should admit in hospital and allowed to continue till
spontaneous onset of labor.
2. Periodic assessment of fetal wellbeing is to be done through
CTG to monitor fetal heart rate and AFI index so that early
evidence of fetal compromise can be deal.

3. Exclude all possible complication such as diabetes, CPD,

toxemia, Rh negative blood.
4. Induction of labor if spontaneous labor is not onset with 1014 days after EDD.
5. complicated post-term pregnancy like contracted pelvis, post
ceasarean pregnancy, malpresentation, elderly primigravida.
6. Association of complication like pre-eclampsia, history of
APH, diabetes, Rh-negative should not allowed to past the
expedted date of delivery

Induction of labor
The induction of labor is an intervention to initiate the
process of labor by artificial means in pregnancies from 24
weeks (period of viability) of gestation which aims at a
vaginal delivery. The decision to induce labour should only
be made when it is clear that a vaginal birth is the most
appropriate mode of delivery in this pregnancy,
Incidence
The incidence of induced labour varies in different hospital
but generally showing a rising trend about 10-15% in india

Indications of induction of labour

Maternal
Prolonged pregnancy
Hypertension including pre-clampsia to expedite the
delivery as severity of symptoms.
Pre-labour rupture of membranes (more than 24 hour)
APH
Elderly primigravidae
Minor degree of placenta praevia
Chronic renal disease
Abruptio placenta

Fetal
Intrauterine growth restriction
Macrosomia
Fetal death
Previous unexplained IUD
Gross congenital anomalies of the fetus
Post maturity
Chronic placental insufficiency
Rh-isoimmunization
Unstable lie
Multiple pregnancy

Contraindications

Contracted pelvic
Malpresentation(transverse or oblique)
Known CPD
Prematurity
Cardiac disease
Elderly primigravida associated with complication
Pelvic tumor
Previous caesarean section
Carcinoma of cervix
Active genital herpes infection
Umbical cord prolapsed
Severe actual fetal compromise
Placenta praevia

Methods of induction
Prior to any method used to induce labour, it is extrem ely
important for the midwife to carry out an abdominal
examination confirming the lie, presentation, descent of
presenting part and fetal wellbeing. Before starting the
induction condition of the cervix should assess, cervical
exam is to be performed.The bishops sore should 6 or
more than 6 is favourable for induction, below 5 is
unfavourable for induction.

The common methods used for induction of

labor are:
1. Medical induction
2. Surgical induction
3. Combined

Medical Induction
In medical induction the drugs are used for labour
induction.
Indications:
i) Exclusive
- Intrauterine death (IUFD)
- Premature rupture of the membrane (PROM)
ii) In case of failure of surgical induction as an
alternative to caesarean section.

Drugs:

Oxytocin
Prostaglandin
Oxytocin
Oxytocin is a hormone released from the posterior
pituitary gland. It acts at cell level on smooth muscle and
is released in a pulsed manner in response to stimulation.
Receptor to oxytocin are found in myometrium and
increase in number at the terms and throught labour.

Principles of Induction of Labour

1. The oxytocin should be started at low dose but
increases quickly where there is no response because
its erractic response.
2. When the optimal responses are achieved (severe
uterine contraction), the administration of the
particular concentration in mu/min is to be
continued. This is called oxytocin titration
technique.
3. The objective of oxytocin administration is not only
to initiate effective contraction but also maintain
normal pattern of uterine activity till delivery and at
least 30-40 minutes beyond that.

Regime of oxytocin
Multigravidae uterus or the uterus which is already
contracting is much more sensitive to oxytocin. In this
respect , the primigravidae uterus is less sensitive.The
patient should preferably lie on one side or in semifowlers position to minimize vanacaval compression.
1. First regimine:- Mix 2.5 unit syntocin in 500 ml of
destrose or ringers lactate and start at 10 drops/minute
to evaluate the sensitivity of the patient to drugs.
Theafter increase the drop rate gradually with 10 drops
in every 30 minutes up to 60 drops per minute depending
on the response that is frequency and strength of uterine
contraction.

If good contraction pattern has not obtained with the infusion rate at
60 drops/min, increase oxytocin concentration to 5 units in 500ml
dextrose or normal saline or ringer lactate.
Second regime:
5 units of oxytocin added to 500 ml dextrose and give approximated
0,5 mu in one drop of infusion. The starting dose low as 30 drops
per minute (5 mu), increase the 10 drops at 30 minute intervals and
maximum of 60 drops per minute (30mu/min) according strength
and frequency of uterine contraction. If good contraction pattern
still has not been establishe using higher concentration of oxytocin
in multigravida and with previous C/S scare, induction has failed
deliver by caesarean section.

Observation during oxytocin infusion

Moniter the mothers pulse, blood pressure and contractions and

check fetal heart rate.
Review for inductions, be sure induction is indicated as failed
induction is usually followed by caesarean section.
Ensure that mother is on her left side.
Record the rate of infusion, duration and frequency of contration
and fetal heart rate on a partograph every 30 minutes.
Moniter FHS every 30 minutes, always immediately after
contraction. If FHS is less than 100 bpm, stop the infusion and
manage for fetal distress.

 Mother receiving oxytocin should never be left alone.

Increase the infusion rate 10 drops per minute every 30 until
good contraction pattern is established ( 3contraction in 10
seconds and each lasting 40 seconds).
Maintain this rate till delivery is completed.
If hyperstimulation occurs ( 4 contraction in 10 minute and
each contraction lasts longer than 60 seconds), stop the
infusion and relax the uterus using tocolytics such as:

turbutaline 250 mcg IV slowly over 5 minutes

Or salbutamole 10 mg in 1 liter IV fluids at 10 drops per minute.

 Do not use oxytocin 10 units in 500 ml (20mIU/min)

in multigravida and women with previous C/S.
Infuse oxytocin at higher concentration (10 unitsin
500 ml) in primigravida.
If good contraction are not established at the
maximum dose, deliver by caesarean section.

PROSTAGLANDIN
Prostaglandins are highly effective in ripening of cervix during
induction of labour. Bishops score should be assessed before using
prostaglandin for the cervix is fabourable or not.
Indications:
Medical termination of pregnancy
Termination of abnormal pregnancy
Missed abortion
IUFD
Molar pregnancy
Major fetal abnormality like anencephaly

Procedure

Moniter the womans pulse, blood pressure and contraction

and check the fetal heart rate.
Record findings on a partograph.
Review for inductions
The prostaglandin is placed high in the posterior fornix of
the vagina and may be repeated after six hours if required.
Moniter uterine contraction and fetal heart rate of all
women undergoing induction of labour with prostaglandins.

 Discontinue use of prostaglandins and begin oxytocin infusion

if:
Membrane rupture
Cervical ripening has been achieved
Good labour has been established
Or 12 hours have passed.
Misoprostol
Use misoprostol to ripen cervix only in highly selected
situations such as: severe pre-eclampsia when the cervix is
unfavourable and safe C/S is not immediately available or the
baby is too premature to survive.

Fetal death is utero if the woman has not gone into spontaneous
labour after four week and platelets are decreasing.
Place misoprostol 25mcg in the posterior fornix of the vagina.
Repeat after six hours if required.
If there is no response after two doses 0f 25cmg, increase to 50
mcg every six hours.
Do not use more than 50mcg at a time and do not exceed foru
doses (200mcg)
Do not use oxytocin within 8 hours of using misoprostol.
Moniter uterine contractions and fetal heart rate.

Surgical induction
The initiation of labour is attempt by surgical method and is almost
exclusively done by rupture of the membranes.
Indication:
1)APH
2) Chronic polyhydramnious
3) Severe pre-eclampsia and eclampsia
4) As combined with medical induction
Contraindication:
i. IUFD
ii. Moderate to severe CPD
iii. Abnormal lie

Combined Method
Refer midwifery B book

Procedure
Review for indication
In areas where HIV and/or hepatitis are highly prevalant, it should leave
the membranes intact for as long as possible to reduce perinatal
transmission of HIV.
Listen and note the fetal heart rate.
Ask the woman to lie on her back with her legs bent, feet together and
knees apart.
Wearing high- level disinfected or sterile gloves, use one hand to
examine the cervix and note the consistency, position, effacement and
dilatation.
Use the other hand to insert an amniotic hook or a kocher clamp into the
vagina.
Guide the clamp or hook towards the membranes along the fingers in
the vagina

 Place two fingers against the membrabes and gently

rupture the membrane with the instrument in other
hand. Allow the amniotic fluid to drain slowly
around the fingers.
Note the color of the fluid(clear, greenish, bloody),
If thick meconium is present, suspect fetal distress.
After ARM listen FHS during and after a
contraction. If FHS is abnormal (less than 100or

 If membrane have been ruptured for 18 hours give

prophylactic antibiotics to reduce group B streptococcus
infection in neonate. Penicillin G 2 million units IV or
Ampicilin 2 g IV every 6 hours until delivery. If there is
no sign of infection after delivery discontinue antibiotics.
If good labour is not established one hour after ARM
begin oxytocin infusion.
If labour is induced because of severe maternal disease,
begin oxytocin infusion at the same time as ARM.