Post term pregnancy includes pregnancies that last longer than 42 weeks. Postdate pregnancies last longer than the established or estimated date of confinement, (i.e., 40 weeks).

Jordan lacks accurate statistics regarding the incidence of post date and its impact on maternal and fetal morbidity and mortality. Worldwide, post date occurs in approximately 5 to 10 percent of pregnancies. Advances in obstetric and neonatal care have lowered theabsolute mortality risk; however, retrospective studies of these so-called post-date pregnancies have found an increased risk to the mother and fetus. The perinatal mortality rate (i.e., stillbirths plus neonatal deaths) of two to three deaths per 1,000 deliveries at 40 weeks' gestation approximately doubles by 42 weeks and is four to six times greater at 44 weeks.

History takingFollow the history taking in the booking procedure in the Antenatal Care chapter and keep inmind the following important data: History of previous pregnancy with occurrence of post date History of risk factors

Physical examinationFollow the steps of physical examination as mentioned in the Antenatal Care chapter and keep in mind the following signs:

* Pelvic examinationPerform a sterile vaginal examination provided there are no contraindications (e.g.,bleeding) to assess the Bishop score (see the Induction of Labor chapter):Cervical effacement and dilation Station and nature of the presenting part

* Investigations Laboratory investigationsCBCABO grouping and Rh typeUrine analysis and culture* UltrasoundAssess fetal gestational age and weightDocument presentationAssess amniotic fluid volume ( see Table 15.1) and biophysical profile ( see Table15.2))Assess placenta site and gradeRule out the presence of any congenital malformations

* Measurement technique:Amniotic fluid index Single deepest pocket Two-diameter pocket

* Oligohydramnios:0 to 5 cm0 to 2 cm0 to 15 cm

* Normal5.1 to 25 cm2.1 to 8 cm15.1 to 50 cm

* Polyhydramnios> 25 cm> 8 cm> 50 cm

* ComponentAmniotic fluid volumeFetal breathing movementsFetal movementFetal toneNon stress test

* Score of 2Single vertical pocket of amniotic fluid is greater than 2 cmOne or more episodes of rhythmic fetal breathing movements of 30 seconds or more within 30 minutesThree or more discrete body or limb movements within 30 minutesAt least one extension of a fetal extremity with return to flexion, or opening or closing of a handReactive

* Score of 0Largest vertical pocket of amniotic fluid is 2 cm or lessAbnormal, absent, or insufficient breathing movementsAbnormal, absent, or insufficient movementsAbnormal, absent, or insufficient fetal toneNon reactive

When performing the fetal heart rate tracing, the woman may be seated or in a lateral recumbent position with lateral tilt.If the tracing is not reactive within the first 20 minutes, the test may be extended another 20 minutes.

If the tracing is not reactive within the first 20 minutes, the test may be extended another 20 minutes.If the tracing remains non reactive, a backup test must be performed in order to exclude intrauterine hypoxia.Back-up tests:A contraction stress test orA full biophysical profile Both are acceptable backup tests.

- Reactive (normal)In a 20-minute period, two or more fetal heart rate accelerations of at least 15 beats per minute above the baseline heart rate.*Each acceleration lasts at least 15 seconds.Fetal movement may or may not be noticed by the woman

- Nonreactive (abnormal)No fetal heart rate accelerations over a 40-minute period.

* Maternal and fetal risksEmergency Cesarean deliveryCephalopelvic disproportionCervical tearDystociaFetal death during deliveryPostpartum hemorrhage

* Neonatal risksAsphyxiaAspirationBone fracturePerinatal deathPeripheral nerve paralysisPneumoniaSepticemia

* ManagementPerinatal morbidity and mortality do not increase appreciably between 40-41 weeks of gestation; however, several complications are associated with longer gestations.

- Plan of deliveryWhen determining a management plan for postdate pregnancy (>40 wk of gestation but

- High-risk pregnancy* In certain cases: Nonreassuring fetal heart tracingOligohydramniosIntra uterine growth restrictionMaternal diseases; hypertension, diabetes, and renal diseasesPrevious more than one cesarean sectionPoor obstetric history; unexplained intrauterine fetal death

The decision is straightforward. In these high-risk situations, pregnancy should not be allowed to exceed 40 weeks of gestation; even earlier delivery is required in these cases.

* Low-risk pregnancyThe following parameters are to be considered when determining the management of post date in the low-risk pregnancy. The certainty of gestational ageCervical examination findingsEstimated fetal weightPast obstetric history

Involving the woman in this discussion is wise because her feelings and understanding of the situation are important as well.Pregnancy should not be allowed to progress beyond 42 weeks of gestation

The question of how a pregnancy between 41-42 weeks should be managed remains a debatable issue. The main argument against a policy of routine induction of labor at 41-42 weeks is that induction increases the rate of cesarean delivery without decreasing maternal and/or neonatal morbidity. A recent review in the Cochrane Library concluded that routine induction in low-risk pregnancies at or after 41 weeks gestation is associated with a reduction in perinatal mortality, with no increase in the rate of instrument deliveries or cesarean delivery.

If the physician decides not to deliver the women, the decision whether to institute antepartum fetal surveillance and what method(s) of surveillance to use must be discussed with the woman, keeping in mind the following principles:

Routine induction at 41 weeks' gestation does not increase the cesarean delivery rate, and may decrease it, without negatively affecting perinatal morbidity or mortality. In fact, there may be both maternal and neonatal benefits to a policy of routine induction of labor in well-dated low-risk pregnancies at 41 weeks' gestation.A policy of routine induction at 40 weeks has few benefits and multiple reasons not to allow a pregnancy to progress beyond 42 weeks.Evidence to suggest that antepartum surveillance improves outcomes before 41 weeks' gestation in low-risk pregnancies is insufficient, and routine use of antepartum surveillance between 40-41 weeks' gestation is not supported by the literature.

*So the management includes:- During the antenatal care visit at 40 weeks of pregnancy the following should be done:Ask about the warning symptoms of pregnancy; vaginal bleeding, ROM, decreased fetal movements, or labor pains.Check BP, and protein in urine.Assess the amniotic fluid index by ultrasound.Perform a non stress test.Sweeping of the membranes

In absence of the warning symptoms, normal BP and no proteinuria, if the amniotic fluid index of more than 8 cm and a reactive fetal heart rate tracing, the woman can be reassured and seen after a weeks time (at 41 weeks). Otherwise induction of labor should be done if any of the previous findings were not met.The woman should be educated about the importance of seeking immediate medical care if any of the warning symptoms have occurred.

During the antenatal care visit at 41 weeks of pregnancy the following should be done:Ask about the warning symptoms of pregnancy; vaginal bleeding, ROM, decreased fetal movements, or labor pains.Check BP, and protein in urine.Assess the amniotic fluid index by ultrasound.Perform a non stress test.

Perform vaginal examination to assess the Bishop scoreIf the cervix is favorable Bishop Score 5, labor should be induced. If the cervix is not favorable (Bishop Score 5), the health care provider should Use some measures to ripen the cervix (See Induction of Labor chapter) or Wait for one week, providing that the woman should attend the antenatal care clinic in between to have an assessment of the amniotic fluid index and a non stress test.

It is necessary to watch for the major potential complications associated with inductions beyond 41 weeks gestation and to have a plan for dealing with each. This plan should be liaised with the neonatologist

* 6.1 Meconium aspiration syndrome.The farther pregnancy progresses beyond 40 weeks, the more likely it is that significant amounts of meconium will be present. This is due to:Increased uteroplacental insufficiency, which leads to hypoxia in labor and activation of the vagal systemThe presence of less amniotic fluid increases the relative amount of meconium in utero.

* Macrosomia Fetal macrosomia can lead to maternal and fetal birth trauma and to arrest of both first and second stage of labor. Mid-pelvic instrument deliveries should not be attempted.The most important part of a delivery plan is being prepared for shoulder dystocia in the event that this unpredictable, anxiety-provoking, and potentially dangerous condition arises.

before it leads to acidosis is critical. (See Normal Labor chapter)Whether continuous fetal monitoring or intermittent auscultation is used, interpretation of the results by a well-trained clinician is of paramount importance.If the fetal heart rate tracing is equivocal, fetal scalp stimulation may provide the reassurance necessary to justify continuing the induction of labor.If there is no reassurance that the fetus is tolerating labor, cesarean delivery is recommended.

* Care of the neonateThe post date newborn is at risk for complications including:Meconium aspirationMacrosomiaRespiratory distress

* First aid managementFollow steps of neonatal resuscitation according to guidelines Provide an appropriate thermal environment (See Normal Labor chapter.)Provide adequate oxygenation by oxygen mask in case of respiratory distress, cyanosis or oxygen saturation less than 88% or by ambu bag in case of irregular gasping respirations, apnea, and persistent cyanosis despite 100% oxygen supplementation by oxygen mask or heart rate < 100 bpm.Flow of oxygen should be 510 L/min. Monitor O2 saturation if pulse oximeter is available (required O2 saturation 8895%).

If the birth weight is > 4kg, monitor for hypoglycemia; Check the glucose level using a glucose strip within the first hour after delivery and prior to feeding to exclude hypoglycemia. If the neonate is stable and normoglycemic, start enteral feeding and continue feeding every 2-3 hours. Care should be taken to ensure adequate feeding. Continue checking the blood glucose until full enteral feeding and 3 normal readings of blood glucose (40-45mg/ml) are met. If the neonate has symptomatic hypoglycemia, give dextrose (10%) in water (D10W) 2 mL IV over 24 min and immediately transport the neonate to the NICU.Monitor the newborn for any sign of birth trauma.Do not discharge the newborn before 48 hours.