PROLONGED
PREGNANCY/POSTMATURITY
MRS KATOLO
INTRODUCTION
• The normal length of pregnancy is from
37 weeks to 42 weeks
• Prolonged pregnancy is also referred to
as post term, post maturity and postdates
pregnancy and is said to be the one that
exceeds 42 weeks of gestation or 294
days calculated from the first day of the
last normal menstrual period.
Cont…
• An average pregnancy is 40 weeks or 280
days.
• The term ‘post –dates’ means that the
patient has gone past her estimated due
date for delivery, that is, he is ‘post –
term’.
• The term ‘post maturity’, however,
suggests some pathology, for instance, the
presence of placental insufficiency.
Cont…
• Prolonged pregnancy and post term are
used synonymously and relate to the
duration of pregnancy and not a maternal
condition ( Fraser [Link], 2006).
• The actual incidence is relatively small as
it occurs in approximately 2% to 12% of
all pregnancies (Paul et al, 2006).
• The most frequent cause of post term
pregnancy is inaccurate dating.
Cont…
• Prolonged pregnancy is the most common
reason for induction of labour.
• About 5% of these neonates show
characteristics of post mature syndrome
(Murray and Mickinney, 2006) .
• The post newborn is at high risk for
morbidity and has a mortality rate two to
three times greater than that of term infants.
However, death is uncommon today because
of the early detection and intervention
(Gloria, 1999).
GENERAL OBJECTIVE
• At the end of the lecture, students should
be able to have an understanding and
knowledge on management of a woman
with prolonged pregnancy.
SPECIFIC OBJECTIVES
1. Define prolonged pregnancy and post
maturity.
2. State the causes of prolonged pregnancy.
3. Outline the risk factors of prolonged
pregnancy
4. Explain the diagnosis of prolonged
pregnancy.
Cont….
5. State the risks and clinical implications
of post term pregnancy.
6. Discuss the management of prolonged
pregnancy.
7. Explain the complications of prolonged
pregnancy.
Cont…
8. Describe the characteristics of a Post
Mature Neonate.
9. Explain the problems associated with a
Post Mature Neonate
9. Discuss the management of a Post
Mature Neonate
DEFINITIONS
• Prolonged pregnancy; Pregnancy that
exceeds 42 weeks gestation or 294 days
past the first day of the mothers last
normal menstrual period (Marcia et al,
2007).
• Post term; Any newborn born after 42
weeks of gestation (Joel et al, 2007).
ABBREVIATIONS
• Intra uterine growth retardation (IUGR);
• Expected date of delivery (EDD);
• Last monthly period (LMP)
CAUSES
• The cause of prolonged pregnancy is idiopathic.
RISK FACTORS
• Miscalculation or inaccurate last menstrual
period.
• Lack of stimulation factors such as oxytocin and
prostaglandins e.g. in women who take high doses
of aspirin or like compounds, which are known to
inhibit the synthesis of prostaglandins.
Cont….
• Lack of stimulus of the cervix and lower
segment by presenting part that is in
malpresentation, occipital posterior position
or short umbilical cord.
• Prime gravidae have a longer mean duration
of pregnancy averaging 288 days because the
first pregnancy tends to last longer than
subsequent pregnancies.
• High parity ( five or more pregnancies)_ the
recurrence risk of post term birth increases
with parity.
Cont…
• Previous post term pregnancy increases
the risk of recurrence in subsequent
pregnancy
• Male gender of the fetus
• Genetic factors may also play a role as
studies show certain genes predispose to
prolonged pregnancy.
• Advanced maternal age is a strong risk
factor (over 35 years)
DIAGNOSIS
• The accurate diagnosis of postdates
pregnancy can be made on by proper dating.
• The estimated date of delivery is most
accurately determined early in pregnancy.
However, the following aid in diagnosis.
History taking
• Establish the first day of the last normal
menstrual period. Then calculate the
expected date of delivery. For the EDD to be
accurate:
Cont….
• The woman should be sure of her LMP
• The period must have been of normal
length and regular.
• Not having been on oral contraceptives
pill.
• Quickening; maternal perception of first
fetal movements at about 16-20 weeks.
Abdominal examination
• On abdominal inspection the pregnancy
appears bigger than the gestational age.
• Abdominal palpation for height of fundus
which will be more than 40 weeks.
Ultra sound scanning
• In patients without reliable clinical data,
ultrasound is beneficial. However,
ultrasonography is most accurate in early
gestation (before 12weeks).
Cont….
• After 12weeks,the crown-rump length
becomes less accurate in determining
gestational age because the fetus begins
to curve.
• Ultra sound can also show placental
calcification and the amount of amniotic
fluid at term which is reduced in
postterm.
RISKS AND CLINICAL IMPLICATIONS
OF POST-TERM PREGNANCY.
FETAL RISKS
• AT the end of pregnancy, the placenta
which supplies the fetus with oxygen,
nutrients and removal of wastes begins to
fail to function properly due to aging or
infarction.
• Therefore, the baby’s health may be at
risk of asphyxia, respiratory distress
syndrome and meconium aspiration. In
addition, the following occurs;
Cont..
• Fetal distress syndrome due to
insufficient oxygen supply to the fetus
• Respiratory distress syndrome is due to
anoxia or meconium aspiration.
• Oligohydraminious occurs due to reduced
urine output by the fetus if it is stressed
and can lead to umbilical cord
compression.
• Hypoglyceamia due to too little glucose
producing in stores.
MATERNAL RISKS
• Risk of perineal tears(third and fourth
degree perineum lacerations) due to
macrosomia
• Assisted instrumental delivery such as
forceps and vacuum extraction.
• Caesarian section due to macrosomia
which may present as cephalo pelvic
disproportion.
Cont…
• Psychological disturbances like anxiety
and/or depression due to current
pregnancy going beyond the expected
date of delivery.
• Postpartum haemorrhage resulting from
invasive procedures like assisted
instrumental delivery.
MANAGEMENT OF PROLONGED PREGNANCY
• The management is usually individualised.
• The pregnant woman should be made
aware that management may alter
depending on the clinical assessment.
• The patient will need pre labour
counseling and will need to be kept fully
informed about the decisions taken.
• There is a trend nowadays to be more
conservative as long as there are no
complications.
Cont…
• If conservative management is chosen,
the midwife must remain alert for signs of
deterioration in the maternal and fetal
conditions.
• This will be achieved by antenatal
surveillance, done as follows:
Cont…
Fetal kick count:
• The mother is required to do a daily kick
count by counting the number of fetal
movements felt in a given period of time
e.g.12 hours and record on the kick chart.
• When less than 10 fetal movements are
felt during a 12 hour period, the fetus is
considered to be at risk.
Cont…
The biophysical profile test:
• This involves doing scoring ultra sound
assessment of the heart rate, fetal
movement, fetal tone, reactivity of the
heart rate and amniotic fluid volume to
predict fetal well-being.
• This is done twice weekly to monitor the
fetal well-being.
Cont…
Cardiotocography (CTG):
CTG is also known as non-stress testing
(NST).
• The fetal heart is monitored and the trace
is assessed for the presence of reactivity
and whether the baseline rate is within
the normal range.
• This is done twice weekly to monitor the
fetal well-being.
Cont….
Amniotic fluid measurement:
• Oligohydramnios can be noticed when
doing abdominal examination.
• On inspection, the abdomen appears
smaller than the expected gestational age
especially when IUGR is present.
• On palpation, the uterus is small and
compact, and fetal parts are easily felt.
• Oligohydramnios is also detected by
ultrasound and amnioscopy.
Cont…
Doppler ultrasound of umbilical
artery-
• This is used to assess fetal and placental
blood flow.
• This could help in predicting a risk of fetal
distress in labour.
• Plasma or urinary oestriol levels can be
performed to detect placental
insufficiency where ultrasound is not
available.
Cont…
Maternal Assessment
• The maternal condition will also be
assessed to rule out any risk factors such
as sudden weight gain, rising in blood
pressure and proteinuria which would
indicate the pre-eclampsia.
• The midwife must also assess the
woman’s psychological condition and
keep her fully informed of her progress.
INDUCTION OF LABOUR
• This refers to stimulation of uterine
contractions prior to the onset of spontaneous
labour.
• If induction of labour is preferred a number of
things have to be considered.
REQUIREMENTS FOR INDUCTION OF
LABOUR
• Ensure that the pregnancy is term (37 to 42
weeks).
• Presentation must be cephalic and engaged.
Cont…
• Pelvimetry should be done to ensure
adequate pelvis.
• Amniocentesis should be done to assess
fetal lung maturity.
• A cervical examination should be
performed before initiating attempts at
labour induction.
Assessment of cervical ripeness using
Bishop scoring.
BISHOP SCORE
Cont…
• Bishop score is calculated based upon the
station of the presenting part and cervical
dilation, effacement, consistency and
position.
• Likelihood of a vaginal delivery after
labour induction is similar to that after
spontaneous onset of labour if the Bishop
score is 8.
PROCESS OF LABOUR INDUCTION.
Using prostaglandin E1(misoprostol)
• A ripening process should be considered
prior to use of oxytocin use when the
cervix is unfavorable.
• Synthetic prostaglandin E1(,misoprostol)
is given in a dose of 25micograms
vaginally every 4 to 6hours until uterine
contractions are 3 in 10 minutes
(maximum of 6 doses) especially if the
Bishop score is less than 5.
Cont…
• An oxytocin infusion may be started if
there is;
1. no adequate contraction pattern,
2. the Bishop score is greater than 5,
3. it has been atleast 3 hours since the last
dose of misoprostol.
Cont…
Using oxytocin
• The uterine response to exogenous
oxytocin administration is periodic uterine
contractions.
• Oxytocin is given intravenously depending
on the woman’s parity.
• For prime gravidas 5iu is given in
1000mls of normal saline/dextrose/Ringer.
For multi gravid 2 to 5iu in 1000mls of
normal saline is given in grand multi para.
• Initial dose is 5drops per minute, increase
every 30 minutes with 5 drops until the
uterus contracts 2 contractions in 10
minutes.
• Maximum being 30 drops per minute and
this should not exeeced 1500mls in 10
hours (Sellers 2012).
• However, progress of labour is closely
monitored as a labour is induced.
Cont…
• This is an active approach to post-term
pregnancy where labour is induced.
• Labour is induced if there is potential harm
on the mother or fetus.
• Together with standard care of a woman in
labour, the following specialized care given:
• Strict monitoring of fetal condition with
cardiotocography throughout the labour or
¼ hourly monitoring of fetal heart rate
where CTG is not available.
Cont…
• Prevention of supine hypotension
syndrome.
• Preparation for possible resuscitation of
the infant; all resuscitative equipment
should be prepared and paediatrician
called to assist in resuscitation.
• Changes in baby`s condition may require
caesarean section delivery.
Caesarian section
Considered if:
• The woman is more than 30 years of age,
particularly with history of previous
infertility.
• The baby is large, that is over 4kg.
• The cervix is unripe.
• Insufficient placental reserve
• Gestational proteinuria hypertension.
CHARACTERISTICS OF POST MATURE NEONATE
• A long thin body appearance because the
neonate have decreased amount of soft
tissue mass particularly subcutaneous fat.
• Deep cracking and peeling skin due to
placental aging and continuity exposure
to amniotic fluid.
• The skull is hard, with narrow sutures and
small fontanelles.
Cont….
• The genitalia are fully developed. For
example; a male baby will have a lot of
rugae on the scorotum and if it’s a female
baby, the labia minora will be well
covered with the labia majora.
• The toe and finger nails are long and
stained with meconium.
• The skeleton is fully developed.
Cont…
• The ear cartilage firm and the breast bud
tissue are palpable.
• The skin is often dry, loose, and peeling
due to decreased subcutaneous tissue.
• The skin may be meconium stained
resulting from meconium passed in utero
due to hypoxia.
PROBLEMS ASSOCIATED WITH POST MATURITY
FETAL DISTRESS
• The effect of uterine contractions on an
already compromised placenta may cause fetal
hypoxia causing the fetus to be distressed.
MECONIUM ASPIRATION.
• Hypoxia and distress may cause relaxation of
the anal sphincter leading to the passage of
meconium while in utero.
• The fetus can aspirate the meconium stained
liquor into the lungs either in utero or during
delivery.
Cont…
HYPOGLYCEAMIA
• May result from nutritional deprivation
and resultant depleted glycogen stores.
HYPOTHERMIA
• This is due to decreased liver glycogen
and brown fat stores.
• This is due to reduced fats which act as
an insulator.
Cont….
POLYCYTHERMIA
• This is the increase in the red blood cell
production coming in as a result of
hypoxia.
BIRTH INJURIES
• There will complete ossification of the
skull bones leading to poor moulding
which contributes to birth injuries
Cont…
SEIZURES
• The neonate can have episodes of
seizures which can come as a result of
the hypoxia experienced during intra
uterine
INTRA UTERINE DEATH
• This can result from acute fetal hypoxia
while it is in uterus and this can lead to
fetal death
MANAGEMENT OF A POST MATURE BABY
• The management is directed at
differentiating the fetus that has post
maturity syndrome from the one who is
large, well nourished and tolerated the
prolonged pregnancy.
• Our goal of management is to identify and
manage the post mature newborn’s
potential problems
Cont…
PSYCHOLOGICAL SUPPORT
• Provide emotional support to the parents
to encourage them as the neonate may
appear with dry cracking skin and
possible aspiration of meconium.
• Explain all the procedures in order to
obtain co-operation.
Cont….
MANTAINING A CLEAR AND
PATENT AIR WAY
• If the amniotic fluid is meconium stained
the baby’s nose and mouth should be
wiped before the baby takes its first
breath to minimize the chances of
meconium aspiration syndrome .
• After birth the direct suctioning of the
trachea is needed.
Cont…
OBSERVATION
• Observe the cardiopulmonary function of
the neonate because of the stress of
labour which is poorly tolerated by the
post mature infant and may lead to severe
birth asphyxia.
• Monitor the apical beat of the neonate
which should be in the range of 120b/m to
160b/m as well as the respirations which
should be between 30 to 60 b/m.
Cont…
• Monitor the skin colour as these neonates
tend to be cyanosed as well as jaundiced.
• There is also need to observe for the
occurrence of convulsions which are likely
to be experienced by the neonate.
• Observe for any injury the neonate can
sustain such cephalo heamatoma and
caput succedenum.
• Other observations are as for any normal
neonate.
cont
PROVISION OF WARMTH
• The post mature neonate tends to suffer
from hypothermia because of their
reduced fat stores.
• The neonate can be nursed together with
the mother through skin to skin contact
hence provision of warmth from the
mother more especially if the condition is
stable.
Cont…
• If the condition of the neonate needs
interventions from neonatal intensive care
unit then the neonate can be nursed in
the pre warmed incubator with an
incubator temperature of (32.5 to 37.7
degrees celcious).
• The environment should be warm enough
to provide enough heat to the neonate as
this baby has low glycogen and brown fat
stores
PREVENTION OF HYPOGLYCAEMIA
• If the neonate is unable to suck. Intravenous fluid
of 10 % of dextrose can be given.
• This can be followed by breast feeding either
expressed or cup and spoon type of feeding until
such a time a baby can breast feed on its own.
• Early initiation of feeding is very important to
prevent hypoglycaemia (within 1 hour) after
delivery.
• Frequent monitoring of blood glucose is very
cardinal to ensure that the neonate is not in a
state of hypoglycemia.
SUMMARY
• Pregnancy is considered prolonged exceeds
294 days or 42 weeks from the first day of
the last monthly period.
• Of all the pregnancies, 12% are post-term
(Paul.D 2006).
• Chances of post-term pregnancies are higher
in first pregnancies and in women who have
had a previous post-term pregnancy.
• The worry with post-term pregnancy is
placental insufficiency.
Cont….
• Labour may progress well as spontaneous
vaginal delivery provided she is monitored
closely in the antenatal period and much more
during labour.
• Induction of labour or caesarian section can
be done depending on the condition of both
the mother and the fetus.
• Therefore,the expectant woman needs to be
prepared psychologically before these
procedures to gain her co-operation and allay
anxiety.
REFERENCES.
• Aaron,[Link]/
article/2613369-overview (2013), Time
16:40PM date 18/01/2016.
• Fraser and cooper (2003). Myles
Textbook for Midwives, 14th edition,
Churchill Livingstone, London.
• Gloria, L. (1999). Introduction to
Maternity and Peadiatric Nursing, 3rd
edition, Philadelphia, London.
Cont…
• Paul, D. et al (2006). Gynaecology and
Obstetrics, Laguna Hills, California, USA.
• Marcia, L. etal (2007). Maternal and Child
Nursing Care, 2nd Edition, Elsevier United
States Of America.
• Murray, S.M. and Mckinney E.S (2006).
Foundation of Maternal-New born
Nursing, Elsevier, United States Of America.
• Sellers, P.M. (2012) Midwifery Text Book.
2nd edition, Juta & Company Ltd, South Africa.
