Predisposing factors

1. Predisposing factors • obesity, null parity, family history of prolonged pregnancy, male fetus, fetal anomaly such as anencephaly • those where the dates are incorrect • those with a normal prolonged gestation where physiological maturity is achieved after 42 weeks • with correct dates and are functionally mature but who do not go into labour at term.

2. the risk of prolonged pregnancy is higher in first pregnancies and subsequently reduces with each following pregnancy,where the father is the same. If there is a different father the risk of prolonged pregnancy is as if it were a first pregnancy. • familial factor in relation to the recurrence of prolonged pregnancy across generations, which involves both the mother and the father.

3. Plan of care for prolonged pregnancy • it should proceed once she has reached 42 weeks. • The concept of ‘plan of care’ for prolonged pregnancy is to determine the most appropriate way forward with the pregnancy in order to ensure the optimum outcome for both mother and baby.

4. with maternal consent, to take should be based on the woman (and partner) receiving the information on the possible benefits and risks of each to enable her to make an informed decision based on informed choice

5. antenatal surveillance which includes cardiotocography (CTG) at least two times a week, and an ultrasound scan to estimate the maximum amniotic fluid pool depth ‘computerised CTG, amniotic fluid index, and assessment of fetal breathing, tone and gross body movements’ • The use of a cervical membrane sweep (CMS) at 41 weeks' gestation has been shown to increase the spontaneous onset of labour before 42 weeks in some nulliparous and parous women

6. The purpose of CMS is to attempt to initiate the onset of labour physiologically thus avoiding the intervention of IOL using prostaglandin, artificial rupture of membranes (ARM) and oxytocin. CMS is designed to separate the membranes from their cervical attachment by introducing the examining fingers into the cervical os and passing them circumferentially around the cervix. The process of detaching the membranes from the decidua results in an increase in the concentration of circulating prostaglandins that may contribute to the initiation of the onset of labour in some individuals • Massage of the cervix can be

7. used when the cervical os remains closed and this process may also cause release of local prostaglandin. If after an appropriate time labour has not started spontaneously the process can be repeated. The practice of CMS is not associated with any increase in maternal or neonatal infection although women report more vaginal blood loss and painful contractions in the 24-hour period following the procedure.

8. A number of authors cite evidence that where there is an active approach and IOL is undertaken beyond 41 weeks there is a reduction in perinatal mortality ‘absolute risk of perinatal death is small’;

9. IOL at 41 weeks led to an increase in the length of hospital stay for the mother and an increase in the caesarean section rate. • the management of prolonged pregnancy centres with regards to fetal risk and neonatal outcome in terms of perinatal mortality and morbidity, • N.B:post dates (40+0 weeks to 41+6 weeks) and prolonged pregnancy (42 weeks) • there are no benefits to a prolonged pregnancy.

10. The midwife's role • The woman and her partner must be given clear and unbiased information ,the benefits and possible risks to enable the woman to make an informed decision based on informed choice. • Whilst the obstetrician will take the lead in such cases

11. Key point in the management of prolonged pregnancy • Accurate EDB determined by LMP and early ultrasound reduces the incidence of pregnancies diagnosed as prolonged. • The length of gestation in some racial groups must also be considered

12. A membrane sweep can be offered from 40 weeks as a means to initiate the onset of spontaneous labour. • beyond term the priority in management should follow the practice for the specific complication. • Where the woman makes the choice antenatal surveillance will necessitate a review of the plan of care and the options available to her.

13. Induction of labour (IOL) • Labour is the process whereby the uterine muscle contracts and retracts leading to effacement and dilatation of the cervix, the birth of the baby, expulsion of the placenta and membranes, and the control of bleeding.

14. IOL is an intervention to initiate the process of labour described above by artificial means and involves the use of prostaglandins, ARM (amniotomy), intravenous oxytocin, or any combination of these • It is the term used when initiating this process in pregnancies from 24 weeks' gestation, the legal definition of fetal viability • Where labour is being induced a full assessment must be made to ensure that any intervention planned will be more benefit than risk for both mother and baby.

15. IOL is more painful than spontaneous onset of labor, require epidural anaesthesia and an assisted birth.

16. Indications for IOL • hypertension, diabetes, fetal growth restriction or macrosomia. • mother may also request to have labour induced, should only be agreed in exceptional circumstances. • There is no guarantee IOL will result in a vaginal birth or positive outcome for mother and/or her baby.

17. Box 19.2 • Indications for induction of labor • Maternal • Prolonged pregnancy exceeds 42 completed weeks or 294 days,because of the increased risk of perinatal mortality and morbidity when the pregnancy continues beyond term.

18. Hypertension, including pre-eclampsia –induction will be influenced by the severity of her symptoms. • Diabetes – the type and severity of diabetes influence the decision to induce. • The risk of fetal macrosomia is increased where diabetic control is poor. • In women with pre- existing type 1 and type 2 diabetes, the risk of adverse perinatal outcome is significantly ,Where the fetus is normally grown, elective IOL is offered after 38 weeks' gestation.

19. Prelabour rupture of membranes – the longer the interval between membrane rupture and birth of the baby increases the risk of infection to mother and fetus. labour will commence within 24 hours of rupture of membranes but women should be offered • Maternal request – this may be for psychological or social reasons. • IOL may be considered from 40 weeks • Fetal • Fetal death . • Fetal anomaly not compatible with life.

20. Some contraindications for IOL:الجدول • Placenta praevia • Transverse lie or compound presentation • HIV-positive women not receiving any anti-retroviral therapy or women on any anti- retroviral therapy with a viral load of 400 copies/ml or more • Active genital herpes • Cord presentation or cord prolapse • Known cephalo-pelvic disproportion (CPD) • Severe acute fetal compromise

21. Methods of induction • The cervix must maintain its integrity during pregnancy and then undergo remodelling • prior to labour. For an induction to be successful the cervix needs to have undergone the changes that will ensure the uterine contractions are effective in the progressive dilatation and effacement of the cervix, descent of the presenting part and the birth of the baby.

22. The cervix is said to be ripe when it has undergone these changes. The Bishop score, is the means by which the ripeness of the cervix is assessed using a scoring that examines four features of the cervix and the relationship of the presenting part to the ischial spines. • Each of these five elements is scored between 0 and 3 on vaginal examination (VE).

23. Whilst a score of ≤6 is considered to be unfavorable, a score of 8 or more suggests a greater probability of a vaginal birth, similar to that when the onset of labour is spontaneous • A ripe or favourable cervix is success with IOL, offering less resistance as the contraction and retraction of the myometrium forces the presenting part down

25. VE to assess the cervix and the likelihood of successful induction • Transvaginal ultrasound assessment of cervical length was found to be superior to the Bishop's score in predicting the success of IOL ,but currently VE remains the most common method of cervical assessment for IOL.

26. Cervical membrane sweep • A cervical membrane sweep (CMS), • recommend it is offered to nulliparous women at the 40- and 41-week antenatal examination and to parous women at the 41-week review. • It is commonly undertaken by a doctor or midwife experienced in the practice and has been shown to reduce the need for further methods to induce labour

27. the woman is to make an informed choice. Some women may find the procedure uncomfortable or painful and they may experience vaginal spotting and abdominal cramps , the procedure was safe in that it did not lead to prelabour rupture of membranes, bleeding or maternal or neonatal infection • to offer CMS at 40/41 weeks is to avoid prolonged pregnancy and is not meant for high-risk cases.

28. تمنياتى للجميع بالتوفيق و النجاح