Prolonged pregnancy
By: H.Biibaa
Obstetric II course
Outline
Definition
Associated risks
Epidemiology
Risk factors
Sings/symptoms
Midwife’s/Nurse role
Management
Summary
Definition
The definition of prolonged pregnancy is as a
pregnancy equal to or more 42 completed
weeks (294 days from the first day of LMP)
(de Miranda et al 2006) taken from WHO
(1977).
This is the standard definition of prolonged
pregnancies. Definition of prolonged
pregnancy is important for the women, to
discuss the options of birth and to avoid
unnecessary intervention
Risks associated with prolonged pregnancy
Fetal and neonatal risks
Prolonged pregnancy is associated with an
increase in perinatal morbidity and
mortality. There is an increased risk of
stillbirth and neonatal death. The
increased mortality is thought to be due to
factors such as utero-placental
insufficiency, meconium aspiration and
intrauterine infection.
Cont.....
Fetal morbidity is also increased, with
higher risks of:
Meconium aspiration.
Macrosomia and larger babies resulting
in:
Prolonged labour.
Cephalo-pelvic disproportion.
Shoulder dystocia.
Cont....
Birth injury resulting in, for example,
brachial plexus damage or cerebral
palsy.
Low five-minute Apgar scores.
Neonatal encephalopathy.
Neonatal seizures.
Features of intrauterine growth
restriction (IUGR) due to placental
insufficiency
Maternal risks
Prolonged pregnancy is also associated with
increased risk for the mother, including:
Obstructed labour
Perineal damage
Instrumental vaginal delivery
Caesarean section
Postpartum haemorrhage
Infection
Cont...
Where labour is induced before the uterus
or cervix are in a favourable state,
obstetric problems may follow which can
have an adverse effect on either mother or
baby, including:
Need for caesarean section.
Prolonged labour.
Postpartum haemorrhage.
Traumatic delivery.
Epidemiology
The use of ultrasound in early pregnancy
for accurate dating is thought to reduce
the number of post-term pregnancies
compared to dating based on the LMP.
5-10% of pregnancies are prolonged
beyond 42 weeks.
Around 20% of pregnant women will need
induction of labour - the majority for post-
term pregnancy.
Risk factors
Previous post-term pregnancy increases the
risk of recurrence in subsequent pregnancies.
Primigravidity.
High maternal BMI is associated with longer
gestation
Anencephaly
When postterm pregnancy truly exists, the
most common cause is
Unknown
Cont.....
Genetic factors. There is an increased risk
of post-term pregnancy for mothers who
were themselves born post-term.
Advanced maternal age.
Symptoms
When post-term, the neonate has lower
than normal amounts of subcutaneous fat
and reduced mass of soft tissue.
The skin may be loose, flaky and dry.
Fingernails and toenails may be longer
than usual and stained yellow from
meconium.
Signs
Before delivery there may be reduced
fetal movement.
A reduced volume of amniotic fluid may
cause a reduction in the size of the uterus.
Meconium-stained amniotic fluid may be
seen when the membranes have ruptured..
Midwife’s role
The interventions necessary when labour is
induced also pose a potential risks to a
mother and the neonate. The woman and her
partner should be fully informed of the risks
and benifits of any management to enable her
to make an informed choice.
The midwife has a role in facilitating the
woman’s right and autonomy by ensuring she
fully understands the options available to her
and appropriate cases acting as the woman’s
advocate
Management
Assessment of gestational age
Accurate dating is important for
minimizing the false diagnosis of post
term pregnancy
Comparison of pregnancy dating by last
menstrual period, ultrasound scanning,
and their combination.
Ultrasound dating
Cont..
Options include: non-stress test NST, (NST
with AFI), Contraction Stress Test
Evaluation of AFI important
Definition of oligo in the postterm not
been established
No vertical pocked more than 2-3 cm
AFI less than 5
May choice- starting at 41 weeks- twice
weekly monitoring including FHR
Cardiotocograph (CTG) (NST + AFI)
Cont....
Active approach: Induction Of Labour (IOL)at
41or 42 completed weeks (NICE, RCOG
2001) routine induction was under taken if
the is uncomplicated. This can be reduction in
perinatal mortality rate.
summary
Postterm pregnancy may in itself be “high
risk”
Establish a EDD early and as precisely as
possible- early sono?
Consider antenatal testing at 41 weeks vs
induction
An unfavorable cervix may not be as much of a
risk factor for c-section as underlying issues-
macrosomia, fetal intolerance to labor, etc.
Patience is important for today’s labor curve
TAHNK YOU
