SPONTANEOUS VAGINAL DELIVERY

IN POST TERM PREGNANCYPresented by

Jane A. Djianzonie 100 100 128R. Pavin Vikneshwaran 100 100 185

Advisordr. Fadjrir, M.Ked (OG), Sp.OG

Mentordr. Rina Sinta Dhanu

SMF ILMU OBSTETRI DAN GINEKOLOGIRSU DR. PIRNGADI MEDAN

2015

INTRODUCTION

INTRODUCTION

Pregnancy usually lasts 40 weeks (280 days) is calculated from the first day of the last menstrual period.

Postterm pregnancy is a pregnancy that lasted more than 42 weeks (294 days) since the first day of the last menstrual period.

Postterm pregnancy incidence between 4-19%, depending on the definition adopted and the criteria used in determining the gestational age.INTR

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INTRODUCTIONIn postterm pregnancy there are changes in placenta, amniotic fluid and fetal circumstances → oligohydramnios, meconium aspiration, asphyxia fetus and shoulder dystocia → increase the risk of poor perinatal outcome increased perinatal mortality

Risk for mothers with postterm pregnancy consist of postpartum bleeding and increased obstetric action.

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THEORYSpontaneous Vaginal

Delivery

The First stage: stage of cervical effacement and dilatationDefinition: the first stage of labour refers to the period from the onset of true uterine contractions to the fully dilation of the cervix, when the diameter of the cervical os measures 10cm.

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Duration:o primigravida = 8-12 ho multigravida = 6-8 h

Phases of the first stage: Latent phase: started when the cervix dilatated

slowly and reached to about 3cm.A. in primigravida = 8hB. in multigravida = 4h - Active phase: rapid dilatation of the cervix to

reach 10cm A. in primigravda = 4hB. in multigravida =2h

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The active phase is divided into:1. Accelerative phase 2 hr2. Slopping phase 2 hr3. Decelerative: 2 hr

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N.B – in primigravida the cervix dilates from above downwards, in multigravida dilatation of the internal os, taking up of the cervix and dilatation of the external os occurs simultaneously.

II-The Second stage of labour: stage of delivery of the fetus.Definition: the second stage of labour refers to the period from complete cervical dilatation to the birth of the fetus.Duration:A.in primigravida =1 hB.in multigravida = ½ h however the timing of the second stage is very different to determine and controversial and can be extended as much as there is progress in descent and no harm to the mother or fetus Sp

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Cardinal sign of delivery Engagement Descent FlexionInternal rotation ExtensionExternal rotationDelivery of the fetal's shoulder

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• After external Rotation• sides of the head are

grasped with two hands, and gentle downward traction is applied until the anterior shoulder appears under the pubic arch

• Next, by an upward movement, the posterior shoulder is delivered

• The rest of the body almost always follows the shoulders without difficulty

Delivery of Shoulder

•Clamping the cord• 4-5 cm , 2-3 cm fetal abdomen two clamps• Plastic cord clamp

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Signs of placental separation1. uterus becomes globular firm.2. Sudden gush of blood.3. Uterus rises (placenta separated ,

passes dawn to lower u-segment.4. Umbilical cord protrudes farther

out of the vagina.

Third Stage Delivery of the PlacentaActive management of third stage• oxytoxin injection in 1 minute after

baby delivery (10 IU intramuscular at lateral vastus muscle).

• Controlled umbilical cord taut.• Uterine fundus massage after

delivery of the placenta.

Fourth stage of labor• Exam placenta , membranes , umbilical

cord• Completeness , anomalies• Hour immediately fallowing delivery is

Critical fourth stage of labor • uterine atony , BP , pulse every 15

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THEORYPost Term Pregnancy

DEFINITION• The international definition of prolonged

pregnancy, endorsed by the American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294 days) or more from the first day of the last menstrual period. It is important to emphasize the phrase “42 completed weeks.” Pregnancies between 41 weeks 1 day and 41 weeks 6 days, although in the 42nd week, do not complete 42 weeks until the seventh day has elapsed.

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INSIDENCE• Approximately 7% of the 4 million babies

born in the United States in 2001 is estimated to have been born at 42 weeks or more. Analysis of 27 677 women born in Norway, an increase of 10% to 27%, if the first birth postterm and to 39% if the twice-born postterm.

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EtiologyEffects of Progesterone• ↓progesterone ↑sensitivity of uterus to oxytocin

The theory of oxytocin• release of less oxytocin from the neurohypophysis pregnant women on advance

gestational age is suspected as a factor in postterm pregnancy

Theory of Cortisol / fetus ACTH • Fetal cortisol placenta ↓progesterone & ↑estrogen ↑ prostaglandin• anencephaly, fetal adrenal hypoplasia and absence of the pituitary gland ↓prod

cortisol postterm

Uterus Neural • pressure on the cervical ganglion of Frankenhauser plexus will excite uterine

contractions• location abnormality, short umbilical cord and the lower part is still high

Hereditary• mother gave birth to a daughter postterm, it is probable that her daughter will

become postterm pregnant

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DiagnosisMenstrual history

History of antenatal care• Pregnancy test• Fetal movement• Fetal heart rate

Position of uterine fundus

Ultrasonography (USG) Examination • The earlier ultrasound examination performed, then the pregnancy

age is obtained will be more accurate

Radiological examination

Examination of amniotic fluid• Levels of Lecithin / spingomielin• Amniotic fluid Tromboplastin activity (AFTA) • Amniotic fluid cytology

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Changes in Post Term Pregnancy

Changes in amniotic fluid

Changes in the placenta

• Fetal weight• postmaturitas syndrome• Fetal distress or perinatal death

Changes in the fetus

• Morbidity / mortality of mothers• emotional aspects

The influence to the motherPOST

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Postmaturity Syndromepeeling, wrinkled and patchy skin

long and thin body, indicate wasting;

opened up of the baby's eyes

unusual alert, old and worried-looking.

wrinkling mostly on the hands and feet palms.

Typically quite long nails.

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Postmaturity Syndrome

Depending on the degree of placental insufficiency occurs postmaturity signs can be divided into three stages, namely: 3

Stage I: The skin shows loss of vernix caseosa and skin maceration in the form of dry, brittle and peeling

Stage II: plus meconium staining of the skin

Stage III: plus a yellowish coloring of the nails, skin and the umbilical cord

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Fetal distress or perinatal death increased after 42 weeks gestation or more, mostly occurs intrapartum. Generally caused by:

Macrosomia can cause dystocia in birth

Placental insufficiency resulting in:• Stunted fetal growth• Oligohydramnios:

cord compression occurs, release of thick meconium

• fetal hypoxia• fetal meconium

aspiration

Congenital defects: mainly due to adrenal

hypoplasia and anencephaly

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Management

Only normal pregnancies should allow to go past the expected date of delivery (EDD)

Terminating the pregnancy will correct the problem

The in utero environment must be monitored for the risk of oligohydramnios and placental insufficiency,

Delivery problems of shoulder dystocia with macrosomic infants, meconium aspiration and hypoxia

must be avoided.

TreatmentPO

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CASE REPORT

Name : DR

Age : 23 years old

Religion : Christian

Race : Batak

Occupation : Housewife

Education : High school (SMA)

MR Num. : 97.11.83

Admission Date : 11 August 2015

PATIENT’S IDENTITYCA

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Mrs DR, 23 yo, G1P0A0, Christian, Batak, Housewife, wife from Mr.H, 33yo,

private servant, came to ER with :

Chief complaint : exited expected date of delivery (EDD).

Strain on labor (-), History of bloody show (-), Histoy of amniotic Fluid Leakage (-)

History of previous disease : -

History of previous med : -

Menstrual History

LNMP : 19/10/2014

EDD : 26/07/2015

ANC : Midwife 2x and SpOG, 4x.

History of Labor

1. This pregnancy

History TakingCA

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Status Present

Sens : CM Anemis : -

BP : 120/80mmhg Icteric : -

HR : 90 times /second Cianoteic : -

RR : 20 times /second Dyspneu : -

Temp : 36,5⁰C Oedem : -

Obstetrics Status

Abdomen : asymetric enlargement,

Fundal height : 4 fingers below proc. Xypoid(31 cm)

Tension Part : Left

Lowest Part : head presentation

Fetal Heart Rate(FHR) : 130 x/i, Reguler

Fetal Movement (FM) : (+)

Uterine Contraction : (-)

Estimated Birth Weight : 3000-3200gr

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Clinical Pelvic Assessment - Sacral Promontory : not palpable

- Shape of sacrum : Concave

- Ischial spine : not prominent

- Pubic arch : Blunt

- Os. Coccygeus : mobile

Conclusion : pelvic adequate

Vaginal Examination (VT) : Cervix closed in tight.

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USG TAS- Single Fetus, Head Presentation, Alive Fetus- Fetal Movement (+)- Fetal Heart Rate (FHR) (+)- Biparietal Diameter : 96mm- Femur Length : 84mm- Abdominal Circum. : 342mm- Placenta Anterior Corpus, Calcification (+)- Amniotic fluid (+) normal range (150mm)- Estimated Fetal Weight : 3000-3200

Conclusion :Single Fetus + Intra uterine pregnancy (42-43 weeks) + Head Presentation + Alive Fetus

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Results Normal Values

Hb 4,10 g% 12-14

Erytrocyte 2,78 x106/mm3 4,5-5,5

Leucocyte 12.8 x103/mm3 4.000-10.000

Ht 16,3 % 36-42

Thrombocyte 164 x103/mm3 150-440 x 103

MCV 58,60 fL 80-97

MCH 14,70 pg 27-33,7

MCHC 25,20 g/dL 31,5-35

RDW 22,90 % 10-15

Protrombin time

- Patient- Control

13,0 detik

15,5 detik

INR 1,03 APTT

- Patient- Control

32,3 detik

33,4 detik

AST/SGOT 22,00 U/L 0-40

SGPT 12,00 U/L 0-40

Glucose Ad Random 92,0 mg/dL <140 mg/dL

Ureum 20,0mg/dL 10-50 mg/dL

Creatinin 0,66mg/dL 0,60-1,20 mg/dL

Total Bilirubin 0,50 0,00-1,20 mg/dL

Direct Bilirubin 0,17 0,05-0,30 mg/dL

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DiagnosisPrimi Gravida + Intrauterine Pregnancy (42 weeks 2days) + Head presentation + Alife Fetus + Non Inpartu + Anemia

Therapy- IVFD RL 20 drips/i

Planning • Improved general condition of the patient.• Transfusion 3 bag (PRC) , a routine blood test is done 6 hours

post-transfusion.• Consult Internal Medicine for Anemic diagnostic confirmation and

tolerance of transfusion.CASE

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Date

11 August 2015 S - O Sens: compos mentis

BP : 120/80 mmHg

HR : 82x/I reguler

RR : 20x/I reguler

T : 36,5°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -

Obstetric Status

Abdomen : Enlarged, Asymmetry

Fetal Movement : (+)

Uterine Contraction : (-)

Fetal Heart Rate : 146 x/i, regular

Vaginal Bleeding : (-)

Defecation and urination (+) normal.

A Primi Gravida + IUP(42 weeks, 2 days) + HP + AF + non inpartu + Anemia

P - IVFD RL 20 gtt/iPlanning :

- Monitor Vital Sign, FHR, Uterine Contraction

- Transfusion PRC 3bag

Date

12 August 2015 S -

O Sens: compos mentis

BP : 120/80 mmHg

HR : 82x/I reguler

RR : 20x/I reguler

T : 36,7°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -

Obstetric Status

Abdomen : Enlarged, Asymmetry

Fetal Movement : (+)

Uterine Contraction : (-)

Fetal Heart Rate : 146 x/i, regular

Vaginal Bleeding : (-)

Defecation and urination (+) normal.

A Primi Gravida + IUP(42 weeks, 3days) + HP + AF + non inpartu + Anemia

P - IVFD RL 20 gtt/iPlanning :

- Monitor Vital Sign, FHR, Uterine Contraction- Transfusion PRC 2-bag, remainder 1bag.- Internal Medicine Consultation : Screening blood

test on Fe Serum and TIBC test.

Date

13 August 2015 S-

OSens: compos mentis

BP : 120/80 mmHg RR : 20x/I reguler

HR : 88x/I regular T : 36,6°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -

Obstetric Status

Abdomen : Enlarged, Asymmetry

Fetal Movement : (+)

Uterine Contraction : (-)

Fetal Heart Rate : 148 x/i, regular

Vaginal Bleeding : (-)

Defecation and urination (+) normal.

Blood Test Result (Post Blood Transfusion)

Hb/ Ht/ Leu/ Plt : 6,50 / 23,10 / 14.900 / 127.000

Fe Serum/ TIBC : 23.00 / 619.000

Internal Medicine Consultation : Iron Deficiency Anemia

APrimi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia

P- IVFD RL 20 gtt/iPlanning :

- Monitor Vital Sign, FHR, Uterine Contraction- Transfusion PRC 1bag- Blood Test – Post Blood Transfusion

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Date

14 August 2015 S Straining to give birth

0900 WIT O Sens: compos mentis

BP : 120/80 mmHg RR : 21x/i reguler

HR : 88x/i, regular T : 36,6°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -

Obstetric Status

Abdomen : Enlarged, Asymmetry

Fetal Movement : (+)

Uterine Contraction : (+), 2 x 10”/10’

Fetal Heart Rate : 148 x/i, regular

Vaginal Bleeding : (-)

Defecation and urination (+) normal.

Vaginal Toucher

Cervix : Axial, Dilation : 5cm, Effacement : 100%, occiput ??, Station of vertex (H II-III), Amnion Sac : (+) Bulging

Glove: bloody show (+), Amnion fluid (-).

A Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia

P - IVFD RL 20 gtt/iPlanning :

• Monitor Vital Sign, FHR, Uterine Contraction• Spontaneus Vaginal Delivery• Partography Assessment on the progress of the delivery process.

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09.00 10.00 11.00

RL RL RL

36 37 37 37 37

c c c c c

0930 0900

1 0 023 tahunDR14 /08/ 15

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Spontaneus Vaginal Delivery with Vacuum Extraction ReportAt 14th August 2015A Baby Girl Born, BW : 3100 gr, Neonatal Lenght : 49 cm, A/S : 8/9, anus (+)

• Mother was laid on the gynecology table with lithotomy position. Emptying the bladder and cleaning the genital area was done. Intravenous catheter is fixed well.

• Head of the baby can be seen at vaginal introitus, evaluations of occiput is at 12. Do the insertion of small size silicon vacuum cup on the occiput. Evaluate wall of the vagina and cervix, is not narrow. Carried out vacuum in conjunction with adequate straining of the mother. Vacuum pressure lowered from 0.2, 0.4 and 0.6. Evaluation, the baby’s head have entered the vaginal introitus. With a controlled pull in the direction of the birth canal, head of baby was born, the vacuum cup is released, then carried bipariental grip of baby head. The head pulled downward to give birth to the front shoulder, pulled upward to release the back shoulder.

• A baby girl is born, BW : 3100gr, neonatal length : 49cm A/S: 8/9, anus (+)

• The umbilical cord clamps in two places and cut them, then the bladder is emptied with urine catheter. Oxytocin 10 IU (1amp) given intramuscular at the mother’s left thigh.

• With traction of umbilical cord and simple massage at the fundus for 5-10 minutes , the placenta was born spontaneously , evaluation : complete.

• Evaluate of birth canal for any lacerations. Evaluation of bleeding no bleeding.

• Mother condition after Vaginal Delivery good

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Neonatal Assessment

Type of Birth : Single baby

Date of Birth : 14 August 2015,

1130 WIT

circumstances of birth: Alive baby, spontaneous cry.

APGAR score : 8/9

Sex : female

Body Weight : 3100gr

Body Length : 49cm

Head Circumference : 33cm

Trauma : not found

Congenital Abnormalities: not found

Consult to Perinatology

Post Term Syndrome

• Dry skin(Patchy Skin): (+)• Skin wrinkles : (+),Dominant

Palm and Soles

• Skin color : (+), Pale

• Long nails : (+)• Lenugo : (-)• Vernix Caseosa : (-)• Long hair : (+)• Skin maceration : (-)• Meconium apiration: (-)

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Therapy Post Delivery- IVFD RL + Oxytocin 10-10-5-5 UI → 20 drips/i- Cefadroxil 2 x 500mg- Mefenamat Acid 3 x 500mg- Metargin 3 x 1tab

Planning • Transfusion 1 bag PRC• Routine blood test is done 6 hours post-transfusion.• Monitoring Vital Sign, Uterine Contraction and Post partum

haemorrhage.

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Time (hours) WIT

13.00 13.15 13.30 13.45 14.15 14.45 15.15

Heart Rate 84 80 88 84 80 90 82

Blood Pressure (mmHg)

120/70 130/90 120/90 130/90 130/80 120/80 130/80

Respiratory Rate

22 22 20 20 20 20 20

Uterine Contraction

Kuat Kuat Kuat Kuat Kuat Kuat Kuat

Bleeding( in cc)

5 5 10 - - - -

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Date

15 August 2015 S -

O Sens: compos mentis

BP : 120/80 mmHg RR : 21x/i reguler

HR : 88x/i, regular T : 36,6°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -

Localized Status

Abdomen : Soepel, Peristaltic (+) normal

Fundus height : 2 finger below the umbical

Vaginal Bleeding : (-) lochia (+) Rubra

Urination : (+) normal.

Defecation : (-), Flatus (+)

Blood Test Result (Post Blood Transfusion – 1bag)

Hb/ Ht/ Leu/ Plt : 9,00 / 30.000 / 13.100 / 92.000

A Post Vaginal Delivery on the indication of occiput anterior position + post partum day 1

P • Cefadroxil 2 x 500mg• Mefenamat Acid 3 x 500mg• Methargin 3 x 1 tab• B- Complex Vitamin 2 x 1 tab

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Date

16 August 2015 S -

O Sens: compos mentis

BP : 120/80 mmHg RR : 20x/i reguler

HR : 80x/i, regular T : 36,5°C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -

Localized Status

Abdomen : Soepel, Peristaltic (+) normal

Fundus height : 2 finger below the umbical

Vaginal Bleeding : (-) lochia (+) Rubra

Urination : (+), normal.

Defecation : (+), normal

A Post Vaginal Delivery on the indication of occiput anterior position + post partum day 2

P • Cefadroxil 2 x 500mg• Mefenamat Acid 3 x 500mg• B- Complex Vitamin 2 x 1 tab

Planning :Discard today. Control Obstetric Polyclinic as outpatient on the 20 th August 2015.

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11 August 2015- Chief Complaint : Post Date!!!!- Lab Test : Anemic : 4.10gr%- Fetus in normal condition- Plan for blood transfusion (3bags)- Consult internal medicine for

diagnostic & blood transfusion tolerance

12 August 2015- Transfusion for 2bag- Check lab 6 hours post transfusion.- Answer from the consultant from

internal medicine : check for Fe Serum & TIBC

13 August 2015- Hb : 6,50- Fe/TIBC : 23.00/619.00- Transfusion 3rd bag and check lab

6hours post transfusion - Answer from the consultant from

internal medicine : Iron deficiency Anemia.

14 August 2015- Straining to give birth- Hb : 9,00gr%- Mother delivered at 1132 WIT,

♀,3100gr, BL: 49cm, HC: 33cm- Patient stabil postpartum

15 & 16 August 2015• Patient is monitor after the

delivery.• Patient is stable and getting better.• Discard today. Control Obstetric

Polyclinic as outpatient on the 20th August 2015.

CASE DISCUSSION

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Theory In this Case?

Defination of Post Term is prolonged pregnancy, endorsed by the American College of Obstetricians and Gynecologists (2004), is 42 completed weeks (294 days) or more from the first day of the last menstrual period.

This patient is completed 42weeks, where the gestational age is 42weeks and 2days.

Post term diagnosed with :1. History Taking

• Menstrual History• Last normal

Menstrual Period (LNMP)

• Expected delivery date (EDD).

2. USG TAS• Gestational Age• AFI <10cm• Calcification of Placenta

Menstrual HistoryLNMP : 19/10/2014EDD : 26/07/2015

Patient came to ER on the 11th August 2015 Gestational Age :(42weeks, 2days)

Result from USG TAS :AFI : 15cmIUP : 42 – 43 weeks with calcification of placenta gr.II.

Theory In this Case?

Post Term Syndrome there will be changes in fetus like :Dry skin (+), Skin wrinkles(+) , Skin will decolorized as the meconium color, Long nails (+) , Lenugo (-), Vernix Caseosa (-), Long hair (+), Skin maceration (+), meconium aspiration (+).

Dry skin (Patchy Skin) : (+)Skin wrinkles : (+),Dominant Palm

and SolesSkin color : (+), PaleLong nails : (+)Lenugo : (-)Vernix Caseosa : (-)Long hair : (+)Skin maceration : (-)Meconium aspiration : (-)

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DIS

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• Whether the treatment in this case was appropriate ?• The extent of general practitioners can do, to

handle the post term pregnancy ?

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erima Kasih!T