03.partus immaturus, prematurus, serotinus

Partus Immaturus, Partus Immaturus, Prematurus, Prematurus, Serotinus.Serotinus.

Dr. Firmansyah, SpOGDr. Firmansyah, SpOG

Bagian Obgin / RSUD Raden MattaherBagian Obgin / RSUD Raden Mattaher

FK-UNJAFK-UNJA

Pengertian Persalinan:Pengertian Persalinan:

PartusPartus adalah suatu adalah suatu proses persalinan hasil proses persalinan hasil konsepsi yang konsepsi yang dapat dapat hiduphidup dari dalam uterus dari dalam uterus melalui vagina ke dunia melalui vagina ke dunia luar.luar.

adalah suatu partus dari hasil konsepsi adalah suatu partus dari hasil konsepsi yang dapat hidup tetapi belum a term yang dapat hidup tetapi belum a term (cukup bulan).(cukup bulan).

- usia kehamilan antara- usia kehamilan antara 20 20 mingguminggu

sampaisampai < 28 minggu,< 28 minggu,

- berat janin antara - berat janin antara 500-1000 gram500-1000 gram..

Partus immaturusPartus immaturus

Partus Partus serotinusserotinus (postmaturus)(postmaturus)

adalah partus yang terjadi 2 minggu adalah partus yang terjadi 2 minggu atau lebih dari waktu partus yang atau lebih dari waktu partus yang diperkirakan (taksiran persalinan).diperkirakan (taksiran persalinan).

Partus prematurusPartus prematurus

adalah suatu partus dari hasil konsepsi adalah suatu partus dari hasil konsepsi yang dapat hidup tetapi belum a term yang dapat hidup tetapi belum a term (cukup bulan).(cukup bulan).

- usia kehamilan antara - usia kehamilan antara 28-36 minggu28-36 minggu

- berat janin antara - berat janin antara 1000-2500 gram1000-2500 gram..

Preterm labor is the presence of Preterm labor is the presence of contractionscontractions of sufficient strength of sufficient strength and frequency to effect and frequency to effect progressive progressive effacement and effacement and dilationdilation of the cervix of the cervix between between 20 and 37 weeks' gestation20 and 37 weeks' gestation..

WHO

Incidence : 6- 10%Incidence : 6- 10%

Spontaneous : 40-50% Spontaneous : 40-50%

PROM : 25-40%PROM : 25-40%

Obstetrically indicated : 20-25%Obstetrically indicated : 20-25%

Most mortality and Most mortality and

morbidity is morbidity is

experienced by babies experienced by babies

born before 34 weeks. born before 34 weeks.

Death Death Respiratory distress syndromeRespiratory distress syndrome HypothermiaHypothermia Hypoglycaemia Hypoglycaemia Necrotising enterocolitis Necrotising enterocolitis Jaundice Jaundice InfectionInfection Retinopathy of prematurity Retinopathy of prematurity

Goldenberg, Obstetrics & Gynecology 11-2002

ThreeThree criteria to document PTL criteria to document PTL (20-37w)(20-37w)

1-1- Regular uterine contractionsRegular uterine contractions occur occur

at 4/20 min. or 8/60 min. at 4/20 min. or 8/60 min.

Plus: progressive change in the cervix. Plus: progressive change in the cervix. 2- Cervical dilatation > 1 cm2- Cervical dilatation > 1 cm..3- Effacement 3- Effacement >> 80%.80%.

American Academy of Pediatrician & ACOG 1997

Inhibition of laborInhibition of labor CorticosteroidCorticosteroid AntibioticsAntibiotics Others.Others.

Bed restBed rest Hydration &Hydration & sedationsedation TocolyticsTocolytics

Until effective strategies are found, efforts Until effective strategies are found, efforts should be aimed at should be aimed at preventing newborn preventing newborn complicationscomplications by: by: CorticosteroidsCorticosteroids AntibioticsAntibiotics against group B strep against group B strep Avoiding traumatic deliveries. Avoiding traumatic deliveries. Delivery in a center with experienced Delivery in a center with experienced

resuscitation teams and resuscitation teams and neonatal neonatal intensive careintensive care

ACOG NEWS RELEASE: November 2002

Intravenous hydration does not Intravenous hydration does not seem to be beneficial, even during seem to be beneficial, even during the period of evaluation soon after the period of evaluation soon after admission, admission,

Women with evidence of Women with evidence of dehydrationdehydration may, however, benefit may, however, benefit from the intervention.from the intervention.

Stan et al (Cochrane Review 2000). In: The Cochrane Library, Issue 1 2003. Oxford

It is reasonable not to use tocolytic It is reasonable not to use tocolytic

drugs, as drugs, as there is no clear evidence there is no clear evidence

that they improve outcomethat they improve outcome. However, . However,

tocolysis should be considered if the tocolysis should be considered if the

few days gained would be put to good few days gained would be put to good

use, such as use, such as completing a course of completing a course of

corticosteroidscorticosteroids, or , or in utero in utero transfertransfer..

RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Most authorities do not Most authorities do not recommend use of tocolytics recommend use of tocolytics at or after 34 weeks' .at or after 34 weeks' .

There is no consensus on a There is no consensus on a lower gestational age limit for lower gestational age limit for the use of tocolytic agents.the use of tocolytic agents.

Goldenberg , Obstetrics &Gynecology 11-2002

Nifedipine = EpilateNifedipine = Epilate

Atosiban= TractocileAtosiban= Tractocile

B-Sympathomimetic (Ritodrine)

Magnesium sulphate (MgSO4)

Indomethacin

Use of beta-agonists should Use of beta-agonists should be restricted to the be restricted to the management of preterm management of preterm labour between 20 and 35 labour between 20 and 35 completed weeks, including completed weeks, including women with ruptured women with ruptured membranes.membranes. (Grade A) (Grade A) RCOG Guideline Grade A recommendation 1997

There is There is insufficient evidenceinsufficient evidence for any for any

firm conclusions about whether or not firm conclusions about whether or not

maintenance tocolytic therapy following maintenance tocolytic therapy following

threatened preterm labor is worthwhile. threatened preterm labor is worthwhile.

Therefore maintenance therapy Therefore maintenance therapy cannot cannot

be recommendedbe recommended for routine practice. for routine practice.

RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Antenatal corticosteroids are associated Antenatal corticosteroids are associated

with a with a significant reductionsignificant reduction in rates of in rates of RDSRDS, ,

neonatal deathneonatal death and and intraventricular intraventricular

haemorrhagehaemorrhage, although the numbers , although the numbers

needed to treat increase significantly after needed to treat increase significantly after

34 weeks' gestation.34 weeks' gestation.

RCOG Guidelines : Grade A Recommendation

The optimal treatment-delivery interval The optimal treatment-delivery interval

for administration of antenatal for administration of antenatal

corticosteroids is corticosteroids is after 24 hours but < after 24 hours but <

7 days7 days after the start of treatment. after the start of treatment.

RCOG Guidelines : Grade A Recommendation

Two 12 mg doses of Two 12 mg doses of betamethasonebetamethasone

given IM 24 hours apart, Orgiven IM 24 hours apart, Or

Four 6 mg doses of Four 6 mg doses of dexamethasonedexamethasone

given IM 12 hours apart (I-A).given IM 12 hours apart (I-A).

There is no proof of efficacy for any There is no proof of efficacy for any

other regimen.other regimen.

SOGC Recommendation Jan. 2003

There is There is no evidenceno evidence of of clear clear overall benefit from overall benefit from prophylactic antibioticsprophylactic antibiotics for for preterm labour preterm labour with intact with intact membranesmembranes on neonatal on neonatal

outcomes.outcomes.

King & Flenady (Cochrane Review August 2002). In: The Cochrane Library, Issue 1 2003. Oxford: Update Software.

ACOG Advises ACOG Advises Screening All Screening All Pregnant Women Pregnant Women

for Group B Strep.for Group B Strep. ACOG NEWS RELEASE November 2002

All patients in preterm labor All patients in preterm labor are considered at high risk for are considered at high risk for neonatal GBS sepsisneonatal GBS sepsis and and should receive prophylactic should receive prophylactic antibiotics regardless of antibiotics regardless of culture status. culture status.


The goal The goal ofof this strategy this strategy

is is to prevent neonatal to prevent neonatal

sepsissepsis, and , and not to prevent not to prevent

preterm birthpreterm birth..


Have notHave not been shown to been shown to significantly prevent significantly prevent periventricular haemorrhages periventricular haemorrhages in preterm infants. in preterm infants.

Goldenberg, May 2003

Crowther & Henderson-Smart (Cochrane Review May 2003 ) In:The Cochrane Library, Issue 1 2003. Oxford: Update Software

Crowther & Henderson-Smart (Cochrane Review Novemb. 2000 ) In:The Cochrane Library, Issue 1 2003. Oxford: Update Software

Various strategies that have Various strategies that have been used to prevent or treat been used to prevent or treat preterm labor, preterm labor, haven't proven haven't proven effectiveeffective..Tocolysis should be considered Tocolysis should be considered only for 2 days-only for 2 days- if needed - for if needed - for corticosteroids thereby , or corticosteroids thereby , or in in utero utero transfer to a tertiary centertransfer to a tertiary center..

If a tocolytic drug is If a tocolytic drug is used, used, ritodrineritodrine no no longer seems the longer seems the best choice.best choice.

Other drugs with fewer adverse effects Other drugs with fewer adverse effects

and comparable effectiveness are now and comparable effectiveness are now

recommendedrecommended..

Atosiban or nifedipineAtosiban or nifedipine have been have been

recommended by RCOGrecommended by RCOG..

IIndomethacinndomethacin may be used as a 2 may be used as a 2ndnd line line

tocolytic or if there is polyhydramnoustocolytic or if there is polyhydramnous..

Maintenance tocolytic therapy Maintenance tocolytic therapy has no proven effect.has no proven effect.

It cannot be recommended for It cannot be recommended for

routine practice.routine practice.

Postterm Postterm PregnancyPregnancy

The term The term postterm, prolonged, postdates,postterm, prolonged, postdates, and and postmaturepostmature are are often loosely used interchangeably to signify pregnancies that often loosely used interchangeably to signify pregnancies that have have exceeded a durationexceeded a duration considered to be the upper limit of considered to be the upper limit of normalnormal..

PostmaturePostmature should be used to described the infant with should be used to described the infant with recognizable clinical featuresrecognizable clinical features indicating a pathologically indicating a pathologically prolonged pregnancyprolonged pregnancy..

PostdatesPostdates probably probably should be abandonedshould be abandoned, because the real , because the real issue in many postterm pregnancies is “post-issue in many postterm pregnancies is “post-whatwhat dates?” dates?”

Therefore, Therefore, posttermpostterm or prolonged pregnancy or prolonged pregnancy is preferred is preferred expression for an expression for an extended pregnancyextended pregnancy..

The standard of definitionThe standard of definition of prolonged pregnancy of prolonged pregnancy: : 42 completed weeks 42 completed weeks (294(294 days)days) or more from the first day of the or more from the first day of the last menstrual periodlast menstrual periodee..

Perinatal mortality rate (stillbirths Perinatal mortality rate (stillbirths plus early neonatal deaths)plus early neonatal deaths) At greater than 42 weeks of gestation At greater than 42 weeks of gestation

is is twicetwice that at term that at term.. 4-7 deaths versus 2-3 deaths per 4-7 deaths versus 2-3 deaths per

11..000 deliveries000 deliveries.. IncreasesIncreases 6-fold and higher at 43 6-fold and higher at 43

weeks of gestation and beyondweeks of gestation and beyond..

Perinatal mortality

The major causes of increased perinatal The major causes of increased perinatal mortality mortality (Lucas and co-workers ,1965)(Lucas and co-workers ,1965)

Pregnancy hypertension Pregnancy hypertension Prolonged labor with cephalopelvic Prolonged labor with cephalopelvic

disproportiondisproportion Intrapartum asphyxiaIntrapartum asphyxia Meconium aspiration syndromeMeconium aspiration syndrome Shoulder dystocia and macrosomiaShoulder dystocia and macrosomia Unexplained anoxiaUnexplained anoxia Malformation Malformation ( i.e., anencephaly, adrenal hypoplasia )( i.e., anencephaly, adrenal hypoplasia )

Pathophysiology

Postmaturity syndromePostmaturity syndrome Postmature infant’s unique Postmature infant’s unique

& characteristic & characteristic appearances by appearances by pathologically prolonged pathologically prolonged pregnancypregnancy Wrinked, patchy, peeling Wrinked, patchy, peeling

skin on the palms and skin on the palms and soles soles

Long, thin body suggesting Long, thin body suggesting wastingwasting

Long nailsLong nails Open-eyed, unusually alert, Open-eyed, unusually alert,

old & worried-looking faceold & worried-looking face Incidence:Incidence: 10% of 10% of

pregnancies pregnancies

between 41between 41 and 43 weeksand 43 weeks

Pathophysiology

Placental dysfunctionPlacental dysfunction

Clifford Clifford (1954) (1954)

Proposed the Proposed the skin changeskin change of postmaturity were due to loss of postmaturity were due to loss of the protective effects of vernix caseosaof the protective effects of vernix caseosa

Stage of postmaturityStage of postmaturity Stage I : clear AF Stage I : clear AF Stage II : skin was stained greenStage II : skin was stained green Stage III : skin discoloration – yellow greenStage III : skin discoloration – yellow green

Attributed the postmaturity syndrome to placental Attributed the postmaturity syndrome to placental senescence, although did not find placental degeneration senescence, although did not find placental degeneration histologicallyhistologically..

Pathophysiology

Jazayeri and co-workers (1998)Jazayeri and co-workers (1998)

Investigated cord erythropoietin levels in 124 appropriately grown Investigated cord erythropoietin levels in 124 appropriately grown newborns delivered from 37 to 43 weeksnewborns delivered from 37 to 43 weeks

To assess whether fetal oxygenation was compromised due to To assess whether fetal oxygenation was compromised due to placental aging in postterm pregnanciesplacental aging in postterm pregnancies

Decreased partial oxygen pressureDecreased partial oxygen pressure is the only known is the only known stimulator stimulator of of erythropoietin erythropoietin

Cord erythropoietin levels → Cord erythropoietin levels → significantly increasedsignificantly increased in pregnancies in pregnancies reaching 41 weeks or morereaching 41 weeks or more


Pathophysiology

The postterm fetus may continue to gain weight, The postterm fetus may continue to gain weight, and thus be an unusually and thus be an unusually large infant at birthlarge infant at birth..

This at least suggests that placental function is This at least suggests that placental function is not compromisednot compromised..

Indeed, continued fetal growth, although at a Indeed, continued fetal growth, although at a slower rate, is characteristic between 38 and 42 slower rate, is characteristic between 38 and 42 weeksweeks..


Pathophysiology

Leveno and associates (1984)Leveno and associates (1984) Antepartum fetal jeopardy & intrapartum fetal distress Antepartum fetal jeopardy & intrapartum fetal distress → → consequence of consequence of cord compressioncord compression associated with associated with

oligohydramniosoligohydramnios In their analysis of 727 postterm pregnancies, In their analysis of 727 postterm pregnancies, intrapartum fetal intrapartum fetal

distress detected with electronic monitoringdistress detected with electronic monitoring was not associated with was not associated with late decelerations characteristic of uteroplacental insufficiencylate decelerations characteristic of uteroplacental insufficiency

One or more One or more prolonged decelerationsprolonged decelerations proceeded three fourths of proceeded three fourths of emergency cesarean deliveries for fetal jeopardyemergency cesarean deliveries for fetal jeopardy

In all but two cases, there were also In all but two cases, there were also variable decelerationsvariable decelerations

Another common fetal heart rate pattern wasAnother common fetal heart rate pattern was the saltatory baseline the saltatory baseline

Fetal distress and Fetal distress and oligohydramniosoligohydramnios

Pathophysiology

Decreased amnionic fluid volumeDecreased amnionic fluid volume commonly develops as commonly develops as

pregnancy advances beyond 42 weekspregnancy advances beyond 42 weeks

Meconium Meconium release into an already reduced amnionic fluid release into an already reduced amnionic fluid volumevolume

→ → causes thick, viscous meconium causes thick, viscous meconium

→ → implicated in implicated in meconium aspiration syndromemeconium aspiration syndrome

Fetal distress and Fetal distress and oligohydramniosoligohydramnios

Pathophysiology

Divon and co-authors Divon and co-authors (1998)(1998) and Clausson and co-workers and Clausson and co-workers (1999)(1999) analyzed births of almost 700 analyzed births of almost 700..000 women between 1991 000 women between 1991 and 1995 using the National Swedish Medical Birth registryand 1995 using the National Swedish Medical Birth registry

StillbirthsStillbirths were more common among were more common among growth-restrictedgrowth-restricted infants who infants who were were delivered at 42 weeks or beyonddelivered at 42 weeks or beyond

Indeed, Indeed, one thirdone third of the postterm stillbirths were growth restricted of the postterm stillbirths were growth restricted

Fetal growth restrictionFetal growth restriction

Pathophysiology

Whether to Whether to interveneintervene at 41 or 42 weeks at 41 or 42 weeks..

Whether Whether labor inductionlabor induction is warranted compared with is warranted compared with expectantexpectant management using antepartum fetal testingmanagement using antepartum fetal testing..

Roussis and colleague Roussis and colleague (1993)(1993) Two thirdsTwo thirds of respondents induced labor at 41 weeks of respondents induced labor at 41 weeks

if the cervix was if the cervix was favorablefavorable.. Antepartum fetal testing was advocated beginning at 41weeksAntepartum fetal testing was advocated beginning at 41weeks

when the cervix was when the cervix was unfavorableunfavorable..

Major issueMajor issue ( (Postterm PregnancyPostterm Pregnancy))

Management

Unfavorable cervix Unfavorable cervix

It is It is difficultdifficult to precisely to precisely definedefine in prolonged pregnancies in prolonged pregnancies

Harris and colleagues Harris and colleagues (1983)(1983) A Bishop score of less than 7A Bishop score of less than 7..

Hannah and colleagues Hannah and colleagues (1992)(1992) Undilated cervixUndilated cervix..

Alexander and associates Alexander and associates (2000)(2000) Women in whom there was Women in whom there was no cervical dilatationno cervical dilatation had a had a twotwo--foldfold

increased cesarean delivery rate for “dystocia”increased cesarean delivery rate for “dystocia”..

Yang and co-worker Yang and co-worker (2004)(2004) Cervical length of 3Cervical length of 3 cm or less → predictive successful inductioncm or less → predictive successful induction..

Management

Unfavorable cervix Unfavorable cervix

Prostaglandin E2Prostaglandin E2 The American college of obstetrician and GynecologistsThe American college of obstetrician and Gynecologists (1997) (1997)

→ → Prostaglandin gel can be safely in postterm pregnancyProstaglandin gel can be safely in postterm pregnancy Use of PG for cervical ripening is discussedUse of PG for cervical ripening is discussed

Sweeping of stripping of the membranesSweeping of stripping of the membranes Boulvain and co-authors (1999)Boulvain and co-authors (1999)

→ → At 38 to 40 weeksAt 38 to 40 weeks decreased the frequency of postterm pregnancy decreased the frequency of postterm pregnancy

→ → Not modify the risk for cesarean deliveryNot modify the risk for cesarean delivery

Station of the vertexStation of the vertex The cesarean delivery rate directly related to stationThe cesarean delivery rate directly related to station 6% if the vertex was -1, 20% at -2, 43% at -3, and 77% at-46% if the vertex was -1, 20% at -2, 43% at -3, and 77% at-4

Management

Bishop scoreBishop score

SKORSKOR 00 11 22 33

Pembukaan serviks (cm)Pembukaan serviks (cm) 0 0 1-21-2 3-43-4 5-65-6

Pendataran serviksPendataran serviks 0-30%0-30% 40-50%40-50% 60-70%60-70% 80%80%

Penurunan kepala (Penurunan kepala (stationstation)) -3-3 -2-2 -1/0-1/0 +1/+2+1/+2

Konsistensi serviksKonsistensi serviks keraskeras sedang sedang lunaklunak

Posisi serviksPosisi serviks posteriorposterior medialmedial anterioranterior

Hannah and colleagues Hannah and colleagues (1992)(1992) Labor inductionLabor induction resulted in a significantly resulted in a significantly lower cesarean ratelower cesarean rate (21%) (21%) compared with pregnancies managed with antepartum testing (24%)compared with pregnancies managed with antepartum testing (24%)

Menticoglou and Hall Menticoglou and Hall (2002)(2002) Lamented that induction of labor at 41 weeks has become standardLamented that induction of labor at 41 weeks has become standard of care in Canadaof care in Canada Because it caused interference that had the Because it caused interference that had the potential to do more potential to do more harm than goodharm than good & have staggering resource implications & have staggering resource implications

Alexander and colleagues Alexander and colleagues (2001, at Parkland Hospital)(2001, at Parkland Hospital) Rates of Rates of cesarean deliverycesarean delivery significantly significantly increasedincreased in the in the induced induced groupgroup because of failure to progress compared with spontaneous because of failure to progress compared with spontaneous labor (19 versus 14%)labor (19 versus 14%).. Risk factors: nulliparity, unfavorable cervix & epRisk factors: nulliparity, unfavorable cervix & epiidural analgesiadural analgesia..

Induction versus fetal testingInduction versus fetal testing

Management

Evidence to substantiate intervention-whether induction or fetal Evidence to substantiate intervention-whether induction or fetal testing-commencing at 41 versus 42 weeks is limitedtesting-commencing at 41 versus 42 weeks is limited

Usher and colleagues (1988)Usher and colleagues (1988)

Perinatal death rates, corrected for malformationsPerinatal death rates, corrected for malformations → → 1.5, 0.7, and 3.01.5, 0.7, and 3.0 per 1000per 1000 for 40, 41, and 42 weeks for 40, 41, and 42 weeks

Based on results summarized in Based on results summarized in Table 37-1Table 37-1, 41-week pregnancies , 41-week pregnancies without other complications → considered without other complications → considered normal pregnanciesnormal pregnancies at at Parkland HospitalParkland Hospital..

Induction versus fetal testingInduction versus fetal testing

Management

When amnionic fluid is decreased in a postterm When amnionic fluid is decreased in a postterm pregnancy-or for that matter in any pregnancy-pregnancy-or for that matter in any pregnancy- the fetus is the fetus is at increased riskat increased risk..

The smaller the amnionic fluid pocket, the greater the The smaller the amnionic fluid pocket, the greater the likelihood that there was clinically significant likelihood that there was clinically significant oligohydramniosoligohydramnios..

Amnionic fluid index (AFI) overestimated the number of Amnionic fluid index (AFI) overestimated the number of abnormal outcomes in postterm pregnanciesabnormal outcomes in postterm pregnancies..

Regardless of the criteria used to diagnosis Regardless of the criteria used to diagnosis oligohydramnios → increased incidence of “oligohydramnios → increased incidence of “fetal distressfetal distress” ” during laborduring labor..

OligohydramniosOligohydramnios

Management

Incidence of macrosomia (defined as Incidence of macrosomia (defined as birthweight greater thanbirthweight greater than 45004500 gg) → increases from ) → increases from 1.4 %1.4 % at 37 to 41 weeks to at 37 to 41 weeks to 2.2 %2.2 % at 42 weeks or more (Marin and colleagues, 2002)at 42 weeks or more (Marin and colleagues, 2002)

Current evidence doesn’t support a policy of early labor Current evidence doesn’t support a policy of early labor induction in women at term who have suspected fetal induction in women at term who have suspected fetal macrosomiamacrosomia..

Cesarean deliveryCesarean delivery recommended for estimated fetal weights recommended for estimated fetal weights greater than 4500greater than 4500 g in the presence of a prolonged second-g in the presence of a prolonged second- stage labor or a second-stage arrest of descentstage labor or a second-stage arrest of descent

MacrosomiaMacrosomia

Management

Recommendations of the ACOGRecommendations of the ACOG (the American College of Obstetricians and (the American College of Obstetricians and

Gynecologists)Gynecologists)

Although providing flexibility in the evaluation & management of Although providing flexibility in the evaluation & management of pregnancies completing 42pregnancies completing 42 weeksweeks → → Antenatal testingAntenatal testing or or labor inductionlabor induction should be commenced should be commenced

Postterm pregnancy has been identified as high-risk condition Postterm pregnancy has been identified as high-risk condition → → twice-weeklytwice-weekly antepartum fetal testing may be indicated antepartum fetal testing may be indicated

OligohydramniosOligohydramnios defined as no vertical pocket of amnionic fluid defined as no vertical pocket of amnionic fluid greater than 2 cm or an AFI of 5 cm or less greater than 2 cm or an AFI of 5 cm or less → → indication for either indication for either deliverydelivery or close or close fetal suveillance fetal suveillance

Management

Postterm PregnancyPostterm Pregnancy

Management

Management at Parkland Hospital Management at Parkland Hospital

In women with a In women with a certaincertain gestational age, labor is induced at the gestational age, labor is induced at the completion of 42 weekscompletion of 42 weeks

90%90% of such women are of such women are induced successfullyinduced successfully

For those who do not deliver with the first inductionFor those who do not deliver with the first induction → → a a second inductionsecond induction is performed within 3 days is performed within 3 days

If not delivered, management decisions involve If not delivered, management decisions involve → → a a thirdthird (or more) (or more) induction induction versus versus cesarean deliverycesarean delivery


Management

Management at Parkland HospitalManagement at Parkland Hospital

Women classified having Women classified having uncertainuncertain postterm pregnancies are postterm pregnancies are followed on a weekly basis & followed on a weekly basis & without interventionwithout intervention unless fetal unless fetal jeopardy is suspectedjeopardy is suspected

Decreased amnionic fluid volumeDecreased amnionic fluid volume & & diminished fetal movementdiminished fetal movement→ → Labor inductionLabor induction as described previously for the woman with as described previously for the woman with a certain postterm gestationa certain postterm gestation


Management

Medical or Obstetrical Complications Medical or Obstetrical Complications

In the event of a medical or obstetrical complicationsIn the event of a medical or obstetrical complications → → unwise to allow a pregnancy to continue past 42 weeksunwise to allow a pregnancy to continue past 42 weeks

In many such instances In many such instances earlyearly delivery is indicateddelivery is indicated

Common examples Common examples Hypertensive disorders due to pregnancyHypertensive disorders due to pregnancy Prior cesarean deliveryPrior cesarean delivery DiabetesDiabetes


Management

Intrapartum Management Intrapartum Management

While being observed for possible laborWhile being observed for possible labor →→ c continuous ontinuous electronicelectronic monitoringmonitoring for variations consistent with fetal for variations consistent with fetal distressdistress

(American College of Obstetricians and Gynecologists, 1995)(American College of Obstetricians and Gynecologists, 1995)

AmniotomyAmniotomy Reduction in fluid volume → the possibility of cord compression Reduction in fluid volume → the possibility of cord compression Diagnosis of thick meconium to be dangerous to the fetus if Diagnosis of thick meconium to be dangerous to the fetus if

aspiratedaspirated Scalp electrode and intrauterine pressure catheter can be placedScalp electrode and intrauterine pressure catheter can be placed


Management


The viscosity of The viscosity of thick meconiumthick meconium

Signifies the lack of liquid & oligohydramniosSignifies the lack of liquid & oligohydramnios

Aspiration Aspiration of thick meconiumof thick meconium → → severe pulmonary dysfunction & neonatal deathsevere pulmonary dysfunction & neonatal death

AmnioinfusionAmnioinfusion during labor as a way of diluting meconium to during labor as a way of diluting meconium to decreasedecrease the incidence of meconium aspiration syndromethe incidence of meconium aspiration syndrome..


Management


The viscosity of The viscosity of thick meconiumthick meconium

The likelihood of a successful vaginal delivery is The likelihood of a successful vaginal delivery is reducedreduced appreciablyappreciably for the nulliparous woman who is in early labor with for the nulliparous woman who is in early labor with thick, thick, meconium-stained amnionic fluidmeconium-stained amnionic fluid

When the woman remote from delivery → prompt When the woman remote from delivery → prompt cesarean cesarean deliverydelivery, ,

especially when cephalopelvic disproportion is suspected or eitherespecially when cephalopelvic disproportion is suspected or either hypertonic or hypertonic dysfunctional labor is evidenthypertonic or hypertonic dysfunctional labor is evident


Management

Intrapartum ManagementIntrapartum Management

Aspiration of meconiumAspiration of meconium

SuctionSuction of the of the pharynxpharynx as soon as the head is delivered as soon as the head is delivered

If meconium is identified , the If meconium is identified , the tracheatrachea should be should be aspiratedaspirated

as soon as possible after deliveryas soon as possible after delivery

The infant should The infant should ventilatedventilated as needed as needed


Management

Thank You

Thank You

03.partus immaturus, prematurus, serotinus

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