Prolonged pregnancy Post term pregnancy = prolonged pregnancy

1. Prolonged pregnancy • Post term pregnancy = prolonged pregnancy • - post maturity : describe neonate that have specific characteristics as long nails ,loose skin ,peeling of epidermis .

2. 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 .

3. * 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

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

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

6. Goal : reach optimum outcome for mother & baby . • Predisposing factors of prolonged pregnancy :

7. @previous prolonged pregnancy . • @male fetus . @ null parity • @body mass index of pregnancy more than 25Kg\M • @anencephaly .

8. 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

9. CTG . • -Monitor FHR with two acceleration of more than 15 seconds ,above base line in 20 minutes . • Any irregularities mean non reassuring CTG .

10. * membrane sweep : • -Done at 41 weeks gestation , Increase onset of spontaneous labor physiologically, to avoid use of prostaglandin ,AROM ,& oxytocin .

11. * 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

12. induction of labor : IOL • *Done at 41 weeks gestation . • Used to uncomplicated pregnancy . • Could be done at 42weeks gestation . • Full assessment should be done .

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

14. @ 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

15. . • @fetal indications : • *IUGR less than 34weeks . • *macrosomia,decrease incidence of shoulder dystocia . • *fetal death . • *fetal anomaly .

16. @ 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.

17. @ 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 .

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

19. @ prostaglandin E2( pGE2) dinoprostone : • -PGE2& PGF2 normally produced by cervix ,uterus ,deciduas ,&fetal membrane . • -act locally on these structure . • -PGE2 vaginal tab. ,gel ,pessaries . • -

20. 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 .

21. * 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 .

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

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

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

25. @ 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 . • -

26. 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 .

27. @ 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 .

28. I.V drip slowly . • Put in normal saline . • Monitor FHR ,& uterine condition . • - observe for hypertonic uterine contraction . • - monitor intensity ,duration ,frequency of uterine contraction .

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

30. ********* midwifery role toward induction of labor : • -proper antenatal care . • -intrapartum care . • -full explanation about induction . • -fill part gram . • -.

31. monitor side effect of each type . • -abdominal examination & vaginal examination . • - u\s . • -give pain relieve

32. * alternative approach to initiate labor : • 1-ingestion of caster oil . • 2-nipple stimulation . • 3-sexual intercourse . • 4-acupuncture . • 5-homeopathic method .