Prolonged pregnancyProlonged pregnancy Post term pregnancy = Post term pregnancy =

prolonged pregnancy prolonged pregnancy - post maturity : describe neonate - post maturity : describe neonate

that have specific characteristics as that have specific characteristics as long nails ,loose skin ,peeling of long nails ,loose skin ,peeling of epidermis .epidermis .

Prolonged pregnancy increase risk of Prolonged pregnancy increase risk of perinatal morbidity & mortality rate perinatal morbidity & mortality rate

.*definition of prolonged .*definition of prolonged pregnancypregnancy : as pregnancy equal to : as pregnancy equal to or more than 42 weeks or 294 days or more than 42 weeks or 294 days from the 1st day of LMP .from the 1st day of LMP .

* *associated risks of associated risks of prolonged pregnancyprolonged pregnancy

;; @mother : @mother : 1- macrosomic infant ( shoulder 1- macrosomic infant ( shoulder

dystocia )dystocia ) 2-genital tract trauma .2-genital tract trauma . 3-post partum hemorrhage .3-post partum hemorrhage . 4-increase risk of operative birth4-increase risk of operative birth

@fetus : @fetus : 1- bone injury .1- bone injury . 2-soft tissue trauma .2-soft tissue trauma . 3-hypoxia .3-hypoxia . 4-cerebral hemorrhage .4-cerebral hemorrhage . 5-still birth . 5-still birth .

@neonate : @neonate : 1- SGA ( small gestational age ) 1- SGA ( small gestational age ) 2- me conium aspiration .2- me conium aspiration . 3-asphyxia .3-asphyxia .

Goal : reach optimum outcome Goal : reach optimum outcome for mother & babyfor mother & baby. .

Predisposing factors of Predisposing factors of prolonged pregnancy :prolonged pregnancy :

@previous prolonged pregnancy .@previous prolonged pregnancy . @male fetus . @ null parity@male fetus . @ null parity

@body mass index of pregnancy @body mass index of pregnancy more than 25Kg\Mmore than 25Kg\M

@anencephaly .@anencephaly .

management of prolonged management of prolonged pregnancypregnancy

consent form need to take by mother consent form need to take by mother

& her husband to do induction of labor & her husband to do induction of labor ..

To assess fetal being do :To assess fetal being do : NST :non stress test & u\s to estimate NST :non stress test & u\s to estimate

AFV by using amniotic fluid index AFI AFV by using amniotic fluid index AFI

CTG .CTG . -Monitor FHR with two acceleration of -Monitor FHR with two acceleration of

more than 15 seconds ,above base more than 15 seconds ,above base line in 20 minutes .line in 20 minutes .

Any irregularities mean non Any irregularities mean non reassuring CTG .reassuring CTG .

* membrane sweep * membrane sweep : : -Done at 41 weeks gestation , -Done at 41 weeks gestation ,

Increase onset of spontaneous labor Increase onset of spontaneous labor physiologically, to avoid use of physiologically, to avoid use of prostaglandin ,AROM ,& oxytocin .prostaglandin ,AROM ,& oxytocin .

* procedure :* procedure : - introducing the examining fingers - introducing the examining fingers

into cervical os & passing them in into cervical os & passing them in circular way around the cervix this circular way around the cervix this lead to increase secretion of lead to increase secretion of prostaglandin at local area this prostaglandin at local area this procedure done also if cervix closed .procedure done also if cervix closed .

Procedure can be repeatedProcedure can be repeated

induction of labor : IOLinduction of labor : IOL

*Done at 41 weeks gestation .*Done at 41 weeks gestation . Used to uncomplicated pregnancy .Used to uncomplicated pregnancy . Could be done at 42weeks Could be done at 42weeks

gestation .gestation . Full assessment should be done .Full assessment should be done .

* indications of IOL * indications of IOL : : 1- PIH .1- PIH . 2- GDM.2- GDM. 3-IUGR.3-IUGR. 4-macrosomia .4-macrosomia . 5-social reason5-social reason

@ maternal indications :@ maternal indications : * prolonged pregnancy .* prolonged pregnancy . *HTN,PIH,according to mother *HTN,PIH,according to mother

symptoms .symptoms . *DM ,still birth ,macrosomia .*DM ,still birth ,macrosomia . *prelabor ROM after 24hours of ROM .*prelabor ROM after 24hours of ROM . *maternal request ,psychological & *maternal request ,psychological &

social reasonsocial reason

.. @fetal indications :@fetal indications : *IUGR less than 34weeks .*IUGR less than 34weeks . *macrosomia,decrease incidence of *macrosomia,decrease incidence of

shoulder dystocia .shoulder dystocia . *fetal death .*fetal death . *fetal anomaly .*fetal anomaly .

@ contraindication of IOL ;@ contraindication of IOL ; * placenta previa .* placenta previa . *transverse lie ( compound presentation .*transverse lie ( compound presentation . *HIV positive woman .*HIV positive woman . * active genital herpes .* active genital herpes . *cord presentation & cord prolapse .*cord presentation & cord prolapse . *known case of CPD *known case of CPD *severe acute fetal compromise. *severe acute fetal compromise.

@ method of induction :@ method of induction : -favorable cervix ( dilated & effaced) .-favorable cervix ( dilated & effaced) . -descent of the presenting part .-descent of the presenting part . -before induction ,abdominal -before induction ,abdominal

examination should be done .examination should be done . -use of bishop score .-use of bishop score . -transvaginal u\s to assess length of -transvaginal u\s to assess length of

the cervix .the cervix .

@ membrane sweep :@ membrane sweep : -done after 40weeks .-done after 40weeks . -carried out by Dr or midwife .-carried out by Dr or midwife . -safe procedure .-safe procedure . -it recommended to do before IOL .-it recommended to do before IOL . Side effect : - doesnSide effect : - doesn’’t reduce the need of IOL .t reduce the need of IOL . - cause discomfort .- cause discomfort . - irregular contraction .- irregular contraction .

@ prostaglandin E2( pGE2) @ prostaglandin E2( pGE2) dinoprostone :dinoprostone :

-PGE2& PGF2 normally produced by -PGE2& PGF2 normally produced by cervix ,uterus ,deciduas ,&fetal cervix ,uterus ,deciduas ,&fetal membrane .membrane .

-act locally on these structure .-act locally on these structure . -PGE2 vaginal tab. ,gel ,pessaries .-PGE2 vaginal tab. ,gel ,pessaries . --

placed in the posterior fornix of the vagina placed in the posterior fornix of the vagina ..

-it absorbed by epithelium of the vagina & -it absorbed by epithelium of the vagina & cervix .cervix .

Action : -relaxation & dilatation of the Action : -relaxation & dilatation of the cervix .cervix .

-uterine muscle contraction .-uterine muscle contraction .

It potentiate the effect of oxytocic It potentiate the effect of oxytocic agent .agent .

* following insertion of * following insertion of prostaglandin : prostaglandin :

1- woman lies down for 30 minutes .1- woman lies down for 30 minutes . 2-attach with CTG .2-attach with CTG . 3-recommended dose PGE23mg tab. 3-recommended dose PGE23mg tab. 4- assess after 6hrs .4- assess after 6hrs . 5- if no response another 3mg inserted 5- if no response another 3mg inserted

in the posterior fornix of the vagina .in the posterior fornix of the vagina . 6-maximum dose 6mg .6-maximum dose 6mg . PGE2gel 4mg .PGE2gel 4mg .

* disadvantages : * disadvantages : Nausea .Nausea . Vomiting .Vomiting . Diarrhea.Diarrhea. N.B :use of oxytocic agent after 6hrs N.B :use of oxytocic agent after 6hrs

of prostaglandin .of prostaglandin .

* PGE1 (misoprostol): * PGE1 (misoprostol): - oral .- oral . -sublingual .-sublingual . -vaginal .-vaginal . -200mcg IOL.-200mcg IOL. -more effective .-more effective . -less expensive .-less expensive . -if used with oxytocic agent cause hyper -if used with oxytocic agent cause hyper

stimulation .stimulation .

-* risk of prostaglandinE2:-* risk of prostaglandinE2: - hypertonic uterus .- hypertonic uterus . -abruptioplacenta .-abruptioplacenta . -fetal hypoxia .-fetal hypoxia . -pulmonary ,amniotic fluid embolism .-pulmonary ,amniotic fluid embolism . -rare uterine rupture .-rare uterine rupture . - c.s delivery .- c.s delivery .

@ AROM :@ AROM : -amniotomy .-amniotomy . -used to induce labor if cervix is favorable & -used to induce labor if cervix is favorable &

fixed presenting part .fixed presenting part . -do abdominal examination before .-do abdominal examination before . -vaginal examination .-vaginal examination . -bag of water lying in front of the presenting -bag of water lying in front of the presenting

part ( fore water) ruptured by amniohook .part ( fore water) ruptured by amniohook . -asses fluid for color ,volume .-asses fluid for color ,volume . --

check FHR .check FHR . -increase risk of chorioamniotis .-increase risk of chorioamniotis . -ascending infection of genital -ascending infection of genital

tract ,increase perinatal mortality rate .tract ,increase perinatal mortality rate . -establish of oxytocin after ROM .-establish of oxytocin after ROM . -PGE2produced from amnion & -PGE2produced from amnion &

cervix ,during pregnancy chorine secret cervix ,during pregnancy chorine secret enzyme called PGDH(prostaglandins enzyme called PGDH(prostaglandins dehydregnase enzyme ) that break dehydregnase enzyme ) that break PGE2thus preterm labor is avoided .PGE2thus preterm labor is avoided .

@ oxytocin :@ oxytocin : -act on smooth -act on smooth muscle ,secreted from posterior muscle ,secreted from posterior pituitary gland .pituitary gland .

receptors of oxytocin found on receptors of oxytocin found on myometrium.. myometrium..

- syntocinon is synthetic of oxytocin - syntocinon is synthetic of oxytocin uterotonic agent . uterotonic agent .

-used for IOL after AROM done .-used for IOL after AROM done .

I.V drip slowly .I.V drip slowly . Put in normal saline .Put in normal saline . Monitor FHR ,& uterine condition .Monitor FHR ,& uterine condition . - observe for hypertonic uterine - observe for hypertonic uterine

contraction .contraction . - monitor - monitor

intensity ,duration ,frequency of intensity ,duration ,frequency of uterine contraction .uterine contraction .

.*risk of oxytocin: .*risk of oxytocin: -hypertonic (hyper stimulation )-hypertonic (hyper stimulation ) - fetal hypoxia .- fetal hypoxia . -uterine rupture .-uterine rupture . -fluid retention .-fluid retention . -post partum hemorrhage .-post partum hemorrhage . -amniotic fluid embolism (AFE)-amniotic fluid embolism (AFE)

********* midwifery role toward ********* midwifery role toward induction of labor :induction of labor :

-proper antenatal care .-proper antenatal care . -intrapartum care .-intrapartum care . -full explanation about induction .-full explanation about induction . -fill part gram .-fill part gram . -.-.

monitor side effect of each type .monitor side effect of each type . -abdominal examination & vaginal -abdominal examination & vaginal

examination .examination . - u\s .- u\s . -give pain relieve-give pain relieve

** alternative approach to initiate alternative approach to initiate labor :labor :

1-ingestion of caster oil .1-ingestion of caster oil . 2-nipple stimulation .2-nipple stimulation . 3-sexual intercourse .3-sexual intercourse . 4-acupuncture .4-acupuncture . 5-homeopathic method .5-homeopathic method .