Prolonged pregnancyPost term pregnancy = prolonged pregnancy - post maturity : describe neonate that have specific characteristics as long nails ,loose skin ,peeling of epidermis .
Prolonged pregnancy increase risk of perinatal morbidity & mortality rate .*definition of prolonged pregnancy : as pregnancy equal to or more than 42 weeks or 294 days from the 1st day of LMP .
* associated risks of prolonged pregnancy;@mother : 1- macrosomic infant ( shoulder dystocia )2-genital tract trauma .3-post partum hemorrhage .4-increase risk of operative birth
@fetus : 1- bone injury .2-soft tissue trauma .3-hypoxia .4-cerebral hemorrhage .5-still birth .
@neonate : 1- SGA ( small gestational age ) 2- me conium aspiration .3-asphyxia .
Goal : reach optimum outcome for mother & baby .
Predisposing factors of prolonged pregnancy :
@previous prolonged pregnancy .@male fetus . @ null parity @body mass index of pregnancy more than 25Kg\M@anencephaly .
management of prolonged pregnancy consent form need to take by mother & her husband to do induction of labor .To assess fetal being do : NST :non stress test & u\s to estimate AFV by using amniotic fluid index AFI
CTG .-Monitor FHR with two acceleration of more than 15 seconds ,above base line in 20 minutes .Any irregularities mean non reassuring CTG .
* membrane sweep : -Done at 41 weeks gestation , Increase onset of spontaneous labor physiologically, to avoid use of prostaglandin ,AROM ,& oxytocin .
* procedure :- introducing the examining fingers into cervical os & passing them in circular way around the cervix this lead to increase secretion of prostaglandin at local area this procedure done also if cervix closed .Procedure can be repeated
induction of labor : IOL
*Done at 41 weeks gestation .Used to uncomplicated pregnancy .Could be done at 42weeks gestation .Full assessment should be done .
* indications of IOL : 1- PIH .2- GDM.3-IUGR.4-macrosomia .5-social reason
@ maternal indications :* prolonged pregnancy .*HTN,PIH,according to mother symptoms .*DM ,still birth ,macrosomia .*prelabor ROM after 24hours of ROM .*maternal request ,psychological & social reason
.@fetal indications :*IUGR less than 34weeks .*macrosomia,decrease incidence of shoulder dystocia .*fetal death .*fetal anomaly .
@ contraindication of IOL ;* placenta previa .*transverse lie ( compound presentation .*HIV positive woman .* active genital herpes .*cord presentation & cord prolapse .*known case of CPD *severe acute fetal compromise.
@ method of induction :-favorable cervix ( dilated & effaced) .-descent of the presenting part .-before induction ,abdominal examination should be done .-use of bishop score .-transvaginal u\s to assess length of the cervix .
@ membrane sweep :-done after 40weeks .-carried out by Dr or midwife .-safe procedure .-it recommended to do before IOL .Side effect : - doesnt reduce the need of IOL . - cause discomfort . - irregular contraction .
@ prostaglandin E2( pGE2) dinoprostone :-PGE2& PGF2 normally produced by cervix ,uterus ,deciduas ,&fetal membrane .-act locally on these structure .-PGE2 vaginal tab. ,gel ,pessaries .-
placed in the posterior fornix of the vagina .-it absorbed by epithelium of the vagina & cervix .Action : -relaxation & dilatation of the cervix . -uterine muscle contraction . It potentiate the effect of oxytocic agent .
* following insertion of prostaglandin : 1- woman lies down for 30 minutes .2-attach with CTG .3-recommended dose PGE23mg tab. 4- assess after 6hrs .5- if no response another 3mg inserted in the posterior fornix of the vagina .6-maximum dose 6mg .PGE2gel 4mg .
* disadvantages : Nausea .Vomiting .Diarrhea.N.B :use of oxytocic agent after 6hrs of prostaglandin .
* PGE1 (misoprostol): - oral .-sublingual .-vaginal .-200mcg IOL.-more effective .-less expensive .-if used with oxytocic agent cause hyper stimulation .
-* risk of prostaglandinE2: - hypertonic uterus .-abruptioplacenta .-fetal hypoxia .-pulmonary ,amniotic fluid embolism .-rare uterine rupture .- c.s delivery .
@ AROM :-amniotomy .-used to induce labor if cervix is favorable & fixed presenting part .-do abdominal examination before .-vaginal examination .-bag of water lying in front of the presenting part ( fore water) ruptured by amniohook .-asses fluid for color ,volume .-
check FHR .-increase risk of chorioamniotis .-ascending infection of genital tract ,increase perinatal mortality rate .-establish of oxytocin after ROM .-PGE2produced from amnion & cervix ,during pregnancy chorine secret enzyme called PGDH(prostaglandins dehydregnase enzyme ) that break PGE2thus preterm labor is avoided .
@ oxytocin : -act on smooth muscle ,secreted from posterior pituitary gland .receptors of oxytocin found on myometrium.. - syntocinon is synthetic of oxytocin uterotonic agent . -used for IOL after AROM done .
I.V drip slowly .Put in normal saline .Monitor FHR ,& uterine condition .- observe for hypertonic uterine contraction .- monitor intensity ,duration ,frequency of uterine contraction .
.*risk of oxytocin: -hypertonic (hyper stimulation )- fetal hypoxia .-uterine rupture .-fluid retention .-post partum hemorrhage .-amniotic fluid embolism (AFE)
********* midwifery role toward induction of labor :-proper antenatal care .-intrapartum care .-full explanation about induction .-fill part gram .-.
monitor side effect of each type .-abdominal examination & vaginal examination .- u\s .-give pain relieve
* alternative approach to initiate labor : 1-ingestion of caster oil .2-nipple stimulation .3-sexual intercourse .4-acupuncture .5-homeopathic method .