POST DATES POST DATES AND AND INDUCTION OF INDUCTION OF LABOURLABOUR

DR. ARIVENDRAN M.D ( UKM ) MRCOG (UK )

DEFINITION

•POSTDATES : Pregnancy after 40 weeks ( after EDD )

•POSTTERM : Pregnancy after 42 weeks ( EDD plus 14

days )

INTRODUCTION• Post-mature births do

not have any harmful effects on the mother; however, the fetus can begin to suffer from malnutrition.

• After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail.

•A number of key morbidities are greater in infants born to postterm pregnancies including meconium and meconium aspiration, neonatal academia, low Apgar scores, macrosomia, and, in turn, birth injury

AETIOLOGY• The causes of post-term

births is unknown. • But post-mature births are

more likely when the mother has experienced a previous post-mature birth.

• Due dates are easily miscalculated when the mother is unsure of her last menstrual period, so in reality the baby is not technically post-mature ( MOST LIKELY )

• Post-mature births can also be attributed to irregular menstrual cycles.

TAKE HOME MESSAGETAKE HOME MESSAGE

•PLEASE ALWAYS TRY DO A DATING SCAN IN THE FIRST TRIMESTER OR THE EARLIEST OPPORTUNITY AVAILABLE

•A DATING SCAN IN THE FIRST TRIMESTER IS ALWAYS MORE RELIABLE THAN HER LAST MENSTRUAL PERIOD

•PLEASE CHECK THE PATIENT’S DATES BEFORE INDUCING

SIGNS OF POST MATURITY

• Dry skin• Overgrown nails, Creases

on the baby's palms and soles of their feet,

• Minimal fat • Brown, green, or yellow

discoloration of their skin

SIGNS OF POST MATURITY• Some postmature babies

will show no or little sign of postmaturity.

COMPLICATIONS OF POST DATESFETAL RISKS

• Reduced placental perfusion

• Calcium is deposited on the walls of blood vessels and proteins are deposited on the surface of the placenta

• Limits the blood flow through the placenta and ultimately leads to placental insufficiency and the

• Fetus is no longer properly nourished.

• OLIGOHYDARMNIOS

• MECONIUM ASPIRATION SYNDROME

MATERNAL COMPLICATIONS

• Increased incidence of forceps assisted, vacuum assisted or cesarean

• Difficulty in delivering the shoulders, shoulder dystocia, becomes an increased risk.

• Increased psychological stress

• Need for induction

METHODS OF MONITORINGFETAL MOVEMENT

CHART

Regular movements of the baby is the best sign indicating that it is still in good health.

The mother should keep a "kick-chart" to record the movements of her baby.

If there is a reduction in the number of movements it could indicate placental deterioration

METHODS OF MONITORINGCARDIOTOCOGRAPH

(CTG)

Electronic fetal monitoring uses a cardiotocograph to check the baby's heartbeat and is typically monitored over a 30-minute period.

METHODS OF MONITORINGULTRASOUND SCAN ( AFI

) If the placenta is

deteriorating, then the amount of fluid will be low and induced labor is highly recommended.

However, ultra sounds are not always accurate

( operator dependant )

Actual placenta won't start to deteriorate until about 48 weeks.

METHODS OF MONITORINGBIOPHYSICAL

PROFILE

A biophysical profile checks for the baby's heart rate, muscle tone, movement, breathing, and the amount of amniotic fluid surrounding the baby.

METHODS OF MONITORINGDOPPLER FLOW STUDY

Doppler flow study is a type of ultrasound that measures the amount of blood flowing in and out of the placenta

TALKING POINTS FOR DISCUSSION• WHAT IS THE REASON FOR THE INDUCTION ?WHAT IS THE REASON FOR THE INDUCTION ?

• WHAT ARE THE ALTERNATIVES TO WHAT ARE THE ALTERNATIVES TO INDUCTION INCLUDING WAITING ?INDUCTION INCLUDING WAITING ?

• WOULD I BE AT RISK OR WOULD MY BABY BE WOULD I BE AT RISK OR WOULD MY BABY BE AT RISK ?AT RISK ?

• HOW DOES AN INDUCTION OCCUR ?HOW DOES AN INDUCTION OCCUR ?

• WHAT ARE THE RISKS OR SIDE EFFECTS WHAT ARE THE RISKS OR SIDE EFFECTS ASSOCIATED WITH INDUCTION ?ASSOCIATED WITH INDUCTION ?

• WHAT IS THE NEXT STEP IF INDUCTION FAILS WHAT IS THE NEXT STEP IF INDUCTION FAILS ??

WHAT IS THE REASON FOR INDUCTION ?

•Women with uncomplicated pregnancies should usually be offered induction of labour between 41+0 and 42+0 weeks to avoid the risks of prolonged pregnancy.

•The exact timing should take into account the woman’s preferences and local circumstances.

UNCOMPLICATED PREGNANCY• Give women every

opportunity to go into labour spontaneously.

• Offer membrane sweeps: - to nulliparous women at

40 week antenatal visit - to all women at 41 week

antenatal visit - 1 week prior to women

you plan to induce - if assessing the cervix.

• Offer induction between 41 and 42 weeks, depending

on woman’s preferences

EVIDENCED BASED PRACTICE• Sweeping the membranes

in women at term reduced the delay between randomisation and spontaneous onset of labour, or between randomisation and birth, by a mean of 3 days.

• Sweeping the membranes

increased the likelihood of both spontaneous labour within 48 hours

WHAT ARE THE ALTERNATIVES TO INDUCTION INCLUDING WAITING ?•Membrane sweeping reduced the

frequency of using other methods to induce labour (‘formal induction of labour’).

•From 42 weeks, women who decline induction of labour should be offered increased antenatal monitoring consisting of at least twice-weekly cardiotocography and ultrasound estimation of maximum amniotic pool depth.

WOULD I BE AT RISK OR WOULD MY BABY BE AT RISK ?

•The risk of Stillbirth increases from 1/3000 ongoing pregnancies at 37 weeks to 3/3000 ongoing pregnancies at 42 weeks to 6/3000 ongoing pregnancies at 43 weeks

•With routine induction, perinatal death was reduced and the rate of caesarean section was reduced

HOW DOES AN INDUCTION OCCUR ?

•NATURAL METHODS

•MECHANICAL METHODS

•PHARMACOLOGICAL METHODS

NATURAL METHODS

•CERVICAL STRETCH AND MEMBRANE SWEEPING

NATURAL METHODS

•NIPPLE STIMULATION

•SEXUAL INTERCOURSE

•ACUPUNCTURE

MECHANICAL METHODS

• FOLLEYS CATHETER

MECHANICAL METHODS

MECHANICAL METHODS

• DILAPAN• LAMINARIA• HYDROPHILIC DILATOR

PHARMACOLGICAL METHODS• PROSTIN• DINOPROSTONE• PROSTAGLANDIN E2

PROSTIN INDUCTION

WHAT ARE THE RISKS AND SIDE EFFECTS ASSOCIATED WITH INDUCTION ?

• UTERINE HYPERSTIMULATION

• FETAL DISTRESS

• FAILED INDUCTION

WRITTEN CONSENT

•MEDICOLEGAL

•COMPULSARY

WHICH IS THE NEXT STEP IF INDUCTION FAILS ?

•EXPECTANT MANAGEMENT

•REINDUCTION

•LOWER SEGMENT CASEREAN SECTION

FAILED INDUCTION

If induction fails, the subsequent management options include:

•– a further attempt to induce labour or to wait (the timing should depend on the clinical situation and the woman’s wishes)

•– caesarean section

BISHOP’S SCORE• Bishop score, also

Bishop's score, is a pre-labour scoring system to assist in predicting whether induction of labour will be required and be successful

• The Bishop score grades patients who would be most likely to achieve a successful induction

MODIFIED BISHOP SCORE• According to the Modified

Bishop's pre-induction cervical scoring system, effacement has been replaced by cervical length in cm

• Points are added or subtracted according to special circumstances as follows:

• One point is added for: ▫ 1. Existence of pre-

eclampsia▫ 2. Every previous vaginal

delivery• One point is subtracted for:

▫ 1. Postdate pregnancy▫ 2. Nulliparity (no previous

vaginal deliveries)▫ 3. PPROM; preterm

premature (prelabor) rupture of membranes

INDICATIONS FOR INDUCTION IN HOSPITAL SEGAMAT

•POSTDATES 7 DAYS ( 41 WEEKS )

•GDM ON TREATMENT AT 38 WEEKS

•PIH ON TREATMENT AT 38 WEEKS

•GDM NOT ON TREATMENT / DIET CONTROL AT EDD

•PROM AFTER 12 – 24 HOURS

LOCAL SETTING• CONSENT TAKEN BY

MEDICAL OFFICERS IN CLINIC OR ON ADMISSION

• DAILY PROSTIN INSERTION (max 3 doses)

• PRIMIDS – 3 mg, • MULTIPS – 1.5 mg

• DONE IN THE WARD BY MEDICAL OFFICERS

•CTG PRIOR TO PROSTIN INSERTION

•PREFERABLY AT 6 AM IN THE MORNING THUS CTG POST PROSTIN CAN BE

REVIEWED DURING MORNING ROUNDS

•PREV LSCS AND GRANDMULTIPARA – FOLLEY’S CATHETER ( kept for 24 hours )

• IF BISHOP SCORE FAVOURABLE >8, ARM AND PITOCIN

THANK YOU FOR YOUR KIND ATTENTION !!!!