Prolonged
Pregnancy
SUBTITLE
▪ Prolonged pregnancy (also known as post-term or post-dates
pregnancy) is used to refer to the 5-10% of pregnancies which persist up
to and beyond 42 weeks gestation.
▪ The primary concern with any prolonged pregnancy is the increased risk
of stillbirth. The rate of stillbirth exponentially rises after 37/40 gestation:
• 37/40 – 1 in 1000
• 42/40 – 3 in 1000
• 43/40 – 6 in 1000
▪ Due to the increased potential for placental insufficiency, there is also a
higher risk of fetal acidaemia and meconium aspiration in labour, and the need
for instrumental or caesarean delivery.
▪ The reduced oxygen and nutrient transfer due to placental degradation can
deplete fetal glycogen stores, resulting in neonatal hypoglycaemia.
▪ Clinical Features
▪ Prolonged pregnancy is a diagnosis based on the gestational age of the
fetus, which is calculated by the first trimester ultrasound dating scan. Thus,
some prolonged pregnancies can have no clinical features at all.
▪ The most common clinical features of a prolonged pregnancy include:
• 1. Static growth or potentially macrosomia
• 2. Oligohydramnios
• 3. Reduced fetal movements
• 4. Presence of meconium
• Signs of meconium staining e.g. on nails
• 5. Dry / flaky skin with reduced vernix
• Vernix is a waxy, white substance found coating the skin of newborn babies.
▪ Management
▪ Guidelines recommend delivery by 42 weeks gestation to reduce the
risk of stillbirth in prolonged pregnancy. This can be achieved by:
• Membrane sweeps – can be offered from 40+0 weeks in nulliparous
and 41+0 weeks in parous women.
• Induction of labour – usually offered between 41+0 and 42+0 weeks
gestation.
• See here for more information.
▪ Women who decline induction of labour should be offered twice
weekly CTG monitoring and USS with amniotic fluid measurement in
an attempt to identify fetal distress. In the event of fetal distress, or
other serious complication to mother or child, it may be necessary to
conduct an emergency caesarean section.
▪ Summary
• At term there is an exponential rise in the number of stillbirths.
• Induction of labour is recommended at 42/40 to reduce this risk.
• First trimester USS dating has helped to reduce errors in calculating due
dates and allows clinicians and patients to plan for delivery if it does not
occur spontaneously before 42 weeks.
• If induction/section is not chosen then increased surveillance is
recommended.
Induction of Labor
▪ Labor induction — also known as inducing labor — is the stimulation of uterine
contractions during pregnancy before labor begins on its own to achieve a vaginal
birth.
▪ A health care provider might recommend labor induction for various reasons,
primarily when there's concern for a mother's health or a baby's health. One of
the most important factors in predicting the likelihood of a successful labor
induction is how soft and distended your cervix is (cervical ripening).
▪ The benefits of labor induction typically outweigh the risks. If you're pregnant,
understanding why and how labor induction is done can help you prepare.
▪ To determine if labor induction is necessary, your health care provider will
evaluate several factors, including your health, your baby's health, your baby's
gestational age, weight and size, your baby's position in the uterus, and the
status of your cervix.
▪ Reasons for labor induction include:
• 1. Postterm pregnancy. You're approaching two weeks beyond your due
date, and labor hasn't started naturally.
• 2. Prelabor rupture of membranes. Your water has broken, but labor hasn't
begun.
• 3. Chorioamnionitis. You have an infection in your uterus.
• 4. Fetal growth restriction. The estimated weight of your baby is less than
the 10th percentile for gestational age.
• 5. Oligohydramnios. There's not enough amniotic fluid surrounding the baby.
• 6. Gestational diabetes. You have diabetes that develops during pregnancy.
• 7. High blood pressure disorders of pregnancy. You have a pregnancy
complication characterized by high blood pressure and signs of damage to
another organ system (preeclampsia), high blood pressure that was present
before pregnancy or that occurs before 20 weeks of pregnancy (chronic high
blood pressure), or high blood pressure that develops after 20 weeks of
pregnancy (gestational hypertension).
• 8. Placental abruption. Your placenta peels away from the inner wall of the
uterus before delivery — either partially or completely.
• 9. Certain medical conditions. You have a medical condition such as kidney
disease or obesity.
▪ Elective labor induction is the initiation of labor for convenience in a person
with a term pregnancy who doesn't medically need the intervention.
▪ Elective labor inductions might be appropriate in some instances.
▪ For example, if you live far from the hospital or birthing center or you have a
history of rapid deliveries, a scheduled induction might help you avoid an
unattended delivery.
▪ In such cases, your health care provider will confirm that your baby's gestational
age is at least 39 weeks or older before induction to reduce the risk of health
problems for your baby.
▪ Labor induction carries various risks, including:
• 1. Failed induction. About 75 percent of first-time mothers who are induced
will have a successful vaginal delivery. This means that about 25 percent of
these women, who often start with an unripened cervix, might need a C-
section. Your health care provider will discuss with you the possibility of a
need for a C-section.
• 2. Low heart rate. The medications used to induce labor — oxytocin or a
prostaglandin — might cause abnormal or excessive contractions, which can
diminish your baby's oxygen supply and lower your baby's heart rate.
▪ 3. Infection. Some methods of labor induction, such as rupturing your
membranes, might increase the risk of infection for both mother and baby.
Prolonged membrane rupture increases the risk of an infection.
• 4. Uterine rupture. This is a rare but serious complication in which your
uterus tears open along the scar line from a prior C-section or major uterine
surgery.
• = Very rarely, uterine rupture can also occur in women who had never had
previous uterine surgery. An emergency C-section is needed to prevent life-
threatening complications. Your uterus might need to be removed.
• 5. Bleeding after delivery. Labor induction increases the risk that your
uterine muscles won't properly contract after you give birth (uterine atony),
which can lead to serious bleeding after delivery.
▪ Labor induction isn't appropriate for everyone. Labor induction might
not be an option if:
• 1. Had a prior C-section with a classical incision or major uterine surgery
• 2. The placenta is blocking your cervix (placenta previa)
• 3. The baby is lying buttocks first (breech) or sideways (transverse lie)
• 4. Have an active genital herpes infection
• 5. The umbilical cord slips into your vagina before delivery (umbilical cord
prolapse)
▪ If you have a prior C-section and have labor induced, your health care
provider will avoid certain medications to reduce the risk of uterine rupture.
▪ Labor induction is done in a hospital or birthing center, where you and
your baby can be monitored and labor and delivery services are readily
available. Some steps might be taken prior to admission.
▪ During the procedure
▪ There are various methods for inducing labor. Depending on the
circumstances, your health care provider might:
▪ 1. Ripen your cervix. Sometimes synthetic prostaglandins, which are typically
placed inside the vagina, are used to thin or soften (ripen) the cervix. After
prostaglandin use, your contractions and your baby's heart rate will be
monitored. In other cases, a small tube (catheter) with an inflatable balloon on
the end is inserted into the cervix. Filling the balloon with saline and resting it
against the inside of the cervix helps ripen the cervix.
▪ 2. Rupture the amniotic sac. With this technique, also known as an
amniotomy, your health care provider makes a small opening in the amniotic
sac with a plastic hook. An amniotomy is done only if the cervix is partially
dilated and thinned and the baby's head is deep in the pelvis
▪ 3. Use an intravenous medication. In the hospital, your health
care provider might intravenously give you a synthetic version of
oxytocin (Pitocin) — a hormone that causes the uterus to
contract.
▪ - Oxytocin is more effective at speeding up (augmenting) labor
that has already begun than it is as a cervical ripening agent.
Your contractions and your baby's heart rate will be continuously
monitored.
▪ Keep in mind that your health care provider might also use a
combination of these methods to induce labor.
▪ After the procedure
▪ In most cases, labor induction leads to a successful vaginal birth. If
labor induction fails, you might need to try another induction or have a
C-section.
▪ If you have a successful vaginal delivery after induction, there might be
no implications for future pregnancies. If the induction leads to a C-
section, your health care provider can help you decide whether to
attempt a vaginal delivery with a subsequent pregnancy or to schedule
a repeat C-section.
