prolonged labour

Question 1

Define a prolongiued pregnancy

Answer 1

beyond the EDD by 2 weeks

Question 2

incidence of prolonged pregnancy

Answer 2

10%

Question 3

causes of prolonged pregnancy

Answer 3

• wrong EDD
• Meridatary
• Maternal factors
  
  • primiparous
  • previous prolonged
  • over 40 y/o
• Fetal factors
  
  • congenital abnormalities
  • macrosomia
• Placental factors
  
  • any abnormalities

Question 4

dg of prolonged pregnancy

Answer 4

• Ask about Menstrual history for EDD
• check weight: 11-12kg normal
• Girth of the abdomen should be over (95cm)
• US
  
  • observe placenta wuality and uteroplacental blood flow
• amniocentesis
  
  • observe amount of amniotic fluid

Question 5

what are the potential complication of prolonged pregnancy

Answer 5

MATERNAL

FETAL

shoulder dystocia

post maturity syndrome

meconium aspiration syndrome,

fetal malnutrition

stillbirths

.

Question 6

management of prolonged pregnancy

Answer 6

induction of labour at 41 weeks

OR

fetal surveillance till 42 weeks

Question 7

why IOL at 41 weeks

Answer 7

reduces the risk of still birth

Question 8

when is the potential for still birth highest

Answer 8

around 1 week post term

Question 9

what does the initiation of IOL in post term preg depend on

Answer 9

if it’s a complicated or uncomplicated case

Question 10

criteria for complicated prolonged pregnancy

Answer 10

fetal post maturity syndrome plus high RF e.g.

• elderly primiparous
• preeclampsia
• RH incompatibility
  
  • oligohydramnious

Question 11

management of complicated prolonged pregnancy

Answer 11

elective C/S

Question 12

how is IOL performed in uncomplicated prolonged pregnacy at 41 weeks if the cervix is unfavourable

Answer 12

Vaginal prostaglandins

• prepare the cervix for labour by ripening it,
• aid contraction of the smooth muscle of the uterus.
• DOSE
  
  • tablet/gel regimen: 1 cycle = 1st dose, plus a 2nd dose if labour has not started 6 hours later.

Pessary regimen: 1 cycle = 1 dose over 24 hours.

Question 13

tablet vaginal prostaglandin dose

Answer 13

1 cycle = 1st dose, plus a 2nd dose if labour has not started 6 hours later.

Question 14

Pessary regimen:

Answer 14

1 cycle = 1 dose over 24 hours.

Question 15

what is the max reccomended dose of vaginal prostaglandins

Answer 15

maximum of one cycle in 24 hours (IOL can sometimes take multiple days).

Question 16

how prolonged pregnancy labour different than normal labour

Answer 16

• longer than normal d/2 larger baby
  
  • requires more analgesia
  • potential for shoulder dystocia

Question 17

what if IOL is declined or fetal monitoring is decided

Answer 17

2x/ weekly CTG monitoring and USS with amniotic fluid measurement to I/D fetal distress.

fetal distress requires emergency C/S

Question 18

what kind of monitoring is required before induction of labour

Answer 18

1. Cervical ripeness
2. CTG

Question 19

how is cervical ripeness measured

Answer 19

BISHOP SCORE

Question 20

what is the Bishop score

Answer 20

an assessment of ‘cervical ripeness‘ based on measurements taken during vaginal examination.

It is checked b4 and during induction to assess progress of prostaglandins

Question 21

when is cervical ripeness measured

Answer 21

• 6 hours post-_tablet/gel_,
• 24 hours post-pessary):

Question 22

meaning of Bishop Score ≥ 7

Answer 22

suggests the cervix is ripe or ‘favourable’

high chance of a response to interventions made to induce labour (i.e. induction of labour is possible).

Question 23

meaning of Bishop Score of <4

Answer 23

suggests that labour is unlikely to progress naturally and prostaglandin tablet/gel/pessary will be required

Question 24

management if Failure of a cervix to ripen despite use of prostaglandins

Answer 24

caesarean section.

Question 25

list the methods of IOL VAMoose

Answer 25

Vaginal Prostaglandins Amniotomy Membrane Sweep

Question 26

what is an amniotomy

Answer 26

where the membranes are ruptured artificially using an instrument called an _amnihook_. * releases prostaglandins in an attempt to expedite labour * only performed when the cervix has been deemed as ‘ripe’ * infusion of artificial oxytocin (**Syntocinon**), to increase the strength and frequency of contractions

Question 27

when is amniotomy used

Answer 27

if the use of prostaglandins are contraindicated e.g. high risk of _uterine hyperstimulation_.

Question 28

what is a MEMBRANE SWEEP?

Answer 28

inserting a _gloved finger_ through cervix and _rotating it against the fetal membranes_, aiming to *separate the **chorionic membrane** from the **decidua***. The separation helps to _release natural prostaglandins_ in an attempt to kick-start labour.

Question 29

when is membrane sweep is offered

Answer 29

_nulliparous_ women 40 and 41 weeks multiparous women : 41 weeks

Question 30

what is IOL

Answer 30

Induction of labour (IOL) is the process of starting labour artificially.

Question 31

indications of IOL

Answer 31

* Prolonged Gestation * Premature Rupture of Membranes * Maternal Health Problems * hypertension, pre-eclampsia, diabetes and obstetric cholestasis. * Fetal Growth Restriction * Intrauterine Fetal Death

Question 32

C.I of IOL

Answer 32

Question 33

what is POST MATURITY SYNDROME

Answer 33

complication of prolonged pregnancy characterized by * wrinkled, patchy scaly skin on palms & soles * overgrown **nails** * long thinning of the body * severe **growth resitriction** * advanced maturity w/ an **alert baby**

Question 34

what is teh pathophys behind post maturity syndrom

Answer 34

* release of proapoptotic genes e.g. ***_KISSEPTIN_*** up regulated in post-term placenta =\> * **placental apoptosis** occurs at **41-42** wks =\> * reduction of fetal oxygenation & blood supply =\> * **↓ amniotic fluid** vol * =\> _meconium release_ * =\>**Meconium aspiration syndrome** * _cord compression_ * both lead to **_FETAL DISTRESS_**

Question 35

what is meconium aspiration syndrome

Answer 35

[https://www.merckmanuals.com/home/children-s-health-issues/lung-and-breathing-problems-in-newborns/meconium-aspiration-syndrome](https://www.merckmanuals.com/home/children-s-health-issues/lung-and-breathing-problems-in-newborns/meconium-aspiration-syndrome)

Question 36

how does the baby appear after felivery of prolonged labour

Answer 36

* Static growth or potentially macrosomia * Oligohydramnios * Reduced fetal movements * Presence of meconium * Signs of meconium staining e.g. on nails * Dry / flaky skin with reduced vernix * ( white substance found coating the skin of newborn babies.)