Obstetrics &

Gynecological Nursing

SUBMITTED TO:
Mrs.R.AMIRTHA GOWRI M.Sc (N)
FACULTY IN NURSING
Mrs.V.VIJAYALAKSHMI M.Sc (N)
FACULTY IN NURSING
COLLEGE OF NURSING
MADURAI MEDICAL COLLEGE
MADURAI.
SUBMITTED BY:
P.REVATHI
 II YEAR M.Sc (N)
CON, MMC, MADURAI

MASTER PLAN ON POSTTERM PREGNANCY

I. Introduction

II. Definition

III. Incidence

IV. Etiology

V. Effects on mother and fetus

VI. Pathophysiology

VII. Signs and symptoms

VIII. Signs of post term infant

IX. Features of post term signature

X. Diagnosis

a. Menstrual history

b. Clinical findings

XI. Investigations

a. Sonography

b. Straight X -ray abdomen

XII. Methods of monitoring post term babies

a. Fetal movement recording

b. Electronic fetal monitoring

c. Ultrasound scanning

d. Biophysical profile
 e. Doppler flow study

XIII. Perinatal risks associated with prolonged pregnancy

XIV. Management

a. Selective induction

b. Management for complicated group

c. Care during labour

XV. Theory application

a. Ramona.T.Mercer theory of ante partum stress and maternal role

attainment

XVI. Nursing process.

 INTRODUCTION

Post maturity refers to a description of the neonate with peeling of the

epidemic long nails, an alert face and loose skin suggestive of recent weight

loss. Prolonged pregnancy is associated with increased risk to the fetus and

neonate resulting in higher perinatal morbidity and mortality. It is the most

common indication given for induction of labour accounting for approximately

46% of inductions overall.

 POST TERM PREGNANCY

Definition:

Post term pregnancy is defined as ‘a pregnancy that exceeds 42 complete

weeks (294 days) after last menstrual period.

It is otherwise known as post maturity or prolonged pregnancy.

Incidence:

Occur in 3% to 12% of all pregnancies. The average is about 10%

Most suspected post term pregnancies are actually wrongly duted.

Etiology:

The actual cause of post term pregnancy is unknown. But certain factors
are related with post maturity.

1. Mother has experienced a previous post mature birth

2. Due dates are easily miscalculated when the mother is unsure of her last
menstrual period. When there is a miscalculation, the baby could be
delivered before or after the expected due data

3. Woman who have irregular menstrual cycles or long menstrual cycles.

(40 to 45 days) do not ovulate on day 14, as in a typical menstrual cycle.
They ovulate 14 days from the end of their cycle or on day 26 to their
child will late by 12 to 17 days.

a. In other, pregnancy is truly overdue.

 4. Occur in a women receiving a high dose of salicylates ( for severe sinus
headaches Rheumatoid arthritis) interfere with synthesis of
prostaglandins (responsible for initiation of labour0

5. Biologic variability (Hereditary) may be seen in the family

6. Maternal factors - primi parity, sedentary habit, elderly primipara

7. Fetal factors - congenital anomalies - anencephaly  Abnormal fetal

HPA axis and adrenal hypoplasia  diminished fetal cortisol response

8. Placental factos - Sulphatase deficiency  low oestrogen

Effects on Mother and Fetus:

 Post mature births do not have any harmful effects on the mother, but the
fetus, however, can begin to suffer from malnutrition. After the 42 nd week
of gestation, the placenta, which supplies the baby with nutrients and
oxygen from the mother starts aging and will eventually fail.

 If the fetus passes fecal matter, which is not typical until after birth, and
the child breathes it in, then the baby could become sick with pneumonia.

PATHOPHYSIOLOGY:

Dangerous for the fetus to remain in utero more than 2wks beyond term

Meconium aspiration fetal intestinal contents likely to reach the rectum

Macrosomia create birth problem usual effect of post term is lack of growth.


 A placenta seems to have a growth potential for only 40 to 42wks. After, it
acquires deposits & cannot function adequately.

Fetus exposed to decreased blood perfuse

Oligohydraminios leading to variable declarations from cord compression

Lack of oxygen, fluid and nutrients if labor not began by 41wks.

Symptoms:

 When post mature the neonate has lower than normal amounts of
subcutaneous fat and reduced mass of soft tissue.

 The skin may be loose, flaky and dry

 Fingernails and toenails may be longer than usual and stained yellow
from meconium

Signs:

 Before delivery there may be reduced fetal movement

 A reduced volume of amniotic fluid may cause a reduction in the size of

the uterus

 Meconium stained amniotic fluid may be seen when the membranes have
ruptured.

Post term Infant:

 Post term infant born after 42nd weeks of pregnancy

  Inducing labour at 2weeks post term to avoid post term births

 An infant who stays in utero post week 42 of pregnancy at risk because of

a placenta appears to function effectively for only 40 weeks

 After this time, it seems to lose its ability to carry nutrients effectively to
the fetus.

 The fetus who remain in utero with a failing placenta may die or
develop” post term syndrome”

FEATURES OF POST TERM SYNDROME:

 Have many of the characteristics of the small for gestational age infant

 Dry, cracked, leather like skin from lack of fluid

 Absence of vernix caseosa

 Light weight from a recent weight loss than occurred because of poor
placental function

 The amount of amniotic fluid may be less at birth that normal, may be
meconium stain

 Fingernails have grown well beyond the end of the fingertips

 Such a babies demonstrate alertness much more like a 2 week old baby
than a newborn.

Diagnosis:

1. Menstrual History:

If the patient is sure about her date with previous history of regular
cycles, it is a fairly reliable diagnosis aid in the calculations of the period of
gestation.
  But in cases of mistaken maturity or pregnancy occurring during
lactational amenorrhea or soon following withdrawal of the pill,
confusion arises, in such cases, the previous well documented antenatal
records of first visit in first trimester are useful guides.

2. The suggested clinical findings:

 Weight record - Regular periodic weight checking reveals stationary or

even falling weight

 Girl of the abdomen - The girth of the abdomen gradually diminishes

because of diminishing liquor

 History of false pain - Appearance of false pain followed by its

subsidence is suggestive

 Obstetric palpation - Height of the uterus, size of the fetus and hardness
of the skill bones. As the liquor amnii diminishes, the uterus feels, “full
of fetus” - a feature usually associated with post maturity.

 Internal examination - A ripe cerise is usually suggestive of fetal

maturity, to find anripe cervix does not exclude maturity.

Feeling of head skull bones either through the cervix or through the
fornix usually suggestions maturity.

INVESTIGATIONS:

1. Sonography:

Accurate assessment of gestational age is the most useful contribution of

ultrasound crown rump length (CRL), biparietal diameter (BPD) and femur
length are the measurement for assessment of gestational age.
2. Straight X-ray abdomen

Thickness and density of the skull bone shadow, appearance and density
of the ossification centers in the upper end of the tibia (38-40weeks) and end of
the femur (36-37weeks) are taken together to assess the maturity.

METHODS OF MONITORING POST MATURE BABIES

Once a baby is diagnosed post mature the mother should be offered

additional monitoring as this can provide valuable clues that the baby health is
being maintained.

1. Fetal movement recording:

Regular movement 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. Less than to movements in 2 hours is not a good sign and a doctor
should be contacted. It there is a reduction in the number of movements it could
indicate placental deterioration.

2. Electronic Fetal monitoring:

Electronic fetal monitoring uses a cardiatocograph to check the baby’s

heart beat and is typically monitored over a 30minutes period. If the heartbeat
proves to be normal the doctor will not usually suggest induced labour.

3. Ultrasound scan:

An ultrasound scan evaluates the amount of amniotic fluid around the

baby. 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 since they also monitor the fetus’s development and if the fetus is
smaller than normal the doctors guess at the age can be quite off. The actual
placenta won’t start to deteriorate until about 48weeks. The reason why doctors
favour induction by 42 weeks is because of the risks are present.

4. Biophysical profile:

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

5. Doppler flow study:

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

PERINATAL RISKS ASSOCIATED WITH PROLONGED

PREGNANCY:

 Beyond around 41 weeks placental function decline and become

insufficient, reducing the supply of oxygen and nutrients to the fetus.
Placental insufficiency increases the risk of intra partum fetal hypoxia.

 There is also increased risk of meconium aspiration syndrome and

neonatal hypoglycemia.

 The risk of stillbirth or neonatal death (in healthy women with normal
pregnancies0 is greater at 42 weeks than 37weeks. The risk has been
shown to be up to 8 times greater at 43weeks.

 The risk of caesarean delivery and maternal complications also increase

with gestational age.

 There is increased risk of fetal macrosomia birth weight > 4kg and birth
injury.

 Some fetal anomalies, e.g. anencephaly

  Increased risk of epilepsy in the neonate particularly if delivered by
instrumental delivery or caesarean section

MANAGEMENT:

UNCOMPLICATED:

1. Selective induction:

The pregnancy may be allowed to continue till spontaneous

onset of labour. Fetal surveillance is continued with modified biophysical
profile twice a week.

2. Routine Induction:

The expectant attitude is extended for 7-10days past the expected

date and thereafter labour is induced.

INDUCTION:

- It is preferable to induce between 10-14 days. Early induction is considered

when there is no reassuring no stress test (NST) there is oligohydramnios.

- If the cervix is favourable (ripe) induce is to be done by stripping of the

membranes by low rupture of the membranes. If the liquor is found clear,
oxytocin infusion is added to be more effective.

- Careful fetal monitoring is mandatory. If the liquor amnii is thickly

meconium stained suggestive of chronic placental insufficiency, caesarean
section is justified.

- If the cervix is unripe, it is made favourable by vaginal administration of

PGE2 gel (prostaglandin E2). This is followed by low rupture of the
membranes.

- Oxytocin infusion is added when required.

COMPLICATED GROUP (ASSOCIATED WITH COMPLICATING
FACTORS).

 Elective caesarean section is advisable when post maturity is associated

with complicating factors like contracted pelvis, post caesarean
pregnancy, mal presentation, elderly primigravida etc.

 Associated complications likely to produce placental insufficiency -

Association of such complications like preeclampsia, history of bleeding
during pregnancy, diabetes and Rh negative pregnancy ideally should not
be allowed to go post the expected date and termination is to be done by
the safest method - Induction or caesarean section.

CARE DURING LABOUR:

Whether spontaneous or induced, the labour is expected to be prolonged

because of a big baby and poor moulding of the head. More analgesia is
required for pain relief possibility of shoulder dystocia is to be kept in mind.
Careful fetal monitoring is to be done. If fetal distress appears prompt delivery
either by caesarean section by forceps / ventouse is to be done.
 THEORY APPLICATION

RAMONA.T. MERCER THEORY OF ANTEPARTUM STRESS AND

MATERNAL ROLE ATTAINMENT:

The effect of ante partum stress on the family functioning.

On antenatal care there is a concern to provide support during pregnancy

to reduce the effects of poor social circumstances, lack of social support and
poor self esteem among women. Mercer and her colleagues have been seeking
to understand the effects of antenatal stress on family functioning as a whole, on
functioning of pairs of individuals in a family, and on health status.

Mercer et al (1986) identify six variables from research and other

literature which are related to health status, dyadic relationships and family
functioning.

1. Ante partum stress

2. Social support
3. Self esteem
4. Sense of mastery
5. Anxiety and
6. Depression
HEALTH STATUS:
The mothers and fathers perception their prior, health, current health,
health outlooks, resistance - susceptibility to illness health worry concerns,
sickness orientation and rejection of sick role.

Infant health status is defined as the extent of any pathology combined

with the parental rating of the infants overall health.
ANTEPARTUM STRESS:

Resulting from a combination of negative life events and the level of risk
associated with the pregnancy.

The family:

A dynamic system which includes subsystems - individuals (mother,

father, fetus/ infant) and dyads (mother - father, mother - fetus / infant and

father - fetus / infant) within the overall family system.

Within the model it is suggested that variables have either negative or

positive effects on family functioning as indicated in this description of the

model.

Stress from negative life events and pregnancy risk were predicted to

have either direct negative effects on self esteem and health status, self esteem,

health status, and social support were predicted to have direct positive effects on

sense of mastery, sense of mastery was predicted to have direct negative effects

on anxiety and depression which in turn have direct negative effects on family

functioning.
MERCERS MODEL OF RELATIONSHIP BETWEEN ANTEPARTUM STRESS AND FAMILY FUNCTIONING

Self esteem

Negative life events sense of mastery

Anxiety

Pregnancy risk Health status

Family functioning

Child birth risk Parental depression

Competence

Social support
 NURSING DIAGNOSES

1. Anxiety related to perceived threat to fetal well being secondary to

complications of pregnancy (placental insufficiency, oligohydramnios

due to post maturity).

2. Anticipatory grieving related to potential for fetal death or injury

3. Risk for impaired fetal gas exchange related to insufficient placental

function, altered cord blood flow.

4. Risk for maternal and fetal injury related to fetal macrosomia, risk for

shoulder dystocia

5. Risk for neonatal /fetal aspiration related to passage of thick meconium in

the amniotic fluid prior to birth

6. Knowledge deficit related to lack of experience or information about fetal

testing.
 NURSING EXPECTED
S.NO GOAL INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
1. Anxiety related to Client will  Assess for physical,  Anxiety may Client will rate anxiety
perceived threat demonstrate a mental, emotional interfere with as less on a scale of 1
to fetal well being decreased level of signs of anxiety like normal to 10. Client will
secondary to anxiety tremors palpitation, physiological & appear calm not
complications of crying etc. mental emotional crying.
pregnancy functioning.
 Ask client to rate  Rating allows
anxiety on a scale of 1 measurement of
to 10 with being calm anxiety level and
& 10 very anxious. changes
 Provide reassurance &  Severe anxiety may
support acknowledge interfere with the
anxiety, allow time for clients ability to
discussion take in information
 Encourage client to  Significant others
involve significant are also under
others in attempts to stress during
identify & cope with complicated
anxiety. pregnancy
 Provide information  Severe anxiety may
about counseling or require individual
support groups counseling, support
(Groups for mature groups provide
parents of post mature reassurance &
baby) coping strategies
 NURSING EXPECTED
S.NO GOAL INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
2. Anticipatory Client and  Assess the client and  Assessment provides Client and significant
grieving related significant significant other’s information and allows other identify the
to potential for other will beliefs about the clarification meaning of the
fetal death or begin the likelihood of perceived possible loss to them,
injury grieving loss.  Client & significant are able to express
process  Provide accurate other may be overly their grief in culturally
information. anxious due to being un appropriate ways.
 Allow & support the informed about current
client and significant situation.
others cultural  Different cultures
expressions of grieving express grief in different
(anger, crying) ways, the nurse needs to
 Support client and allow & facilitate grief
significant other in the work.
stage they are in &  Assist the client &
assist with reality others to work through
orientation. the process without
 Allow visitors us client feeling disapproval.
wishes.  Client advocacy, may
 Offer to contact the wish no visitors or a
client allergy or the large support group.
hospital chap lain if  Religious support may
needed. be helpful to some
clients.
 NURSING EXPECTED
S.NO GOAL INTERVENTIONS RATIONALE
DIAGNOSIS OUTCOME
3. Risk for impaired Fetus will  Assess for fetal growth  Provide information Fetal growth will
fetal gas demonstrate pattern compared to about adequacy of be appropriate for
exchange related adequate gas expected rate by placental nutrient gestational age,
to insufficient exchange for fundal height or ultra transfer to rule out FHR between 10 -
placental intrauterine sound reports. IUGR. 160 without late
functional altered environment.  Assess any vaginal  Assessment provide or severe variable
cord blood flow. discharge fluid, information about cause decelerations
bleeding of hypovolemia,
 Assess FMR for base anemia.
line rate, variability,  Assessment provides
accelerations & information about
decelerations oxygenation, cord
 Perform NST, OCTE compression placental
the as ordered. perfusion
Monitor results.  Testing provides
 Position client on left information about fetal
side or semi fowlers reserve.
with wedge under  Facilitates placental
right hip perfusion by avoiding
 Administer compression of the
medicationing as venacava
ordered  To improve the fetal
well being.
CONCLUSION:

Till now we have discussed about definition, incidence, etiology,

pathophysiology, signs and symptoms, diagnose, investigations of post maturity
and management, nursing process. I thank our madam Mrs.R.Amirtha gowri
M.Sc (N) and Mrs.V.Vijayalakshmi M.Sc (N) for giving this opportunity.

BIBLIOGRAPHY:

1. Myles (2009) “Text book for Midwives”, 15th edition, Philadelphia,

Churchill living stone Elsevier.

2. B.T. Basavanthappa (2006) “Text book of Maternity and Reproductive

health Nursing” 1st edition, New Delhi, Jaypee brothers.

3. D.C.Dutta (2004) “Text book of Obstetrics” 6th edition, Calcutta, New

central book agency (p) ltd.

4. Lynna .Y.Littletone (2002), “Maternal Neonatal and Women’s health

nursing”, Canada, Delmar Thomson Learning Publishers

5. Adele pilliteri (2003) “Maternal and Child health Nursing” 4th edition,
Philadelphia. Lippincott William and Wilsons (p) ltd.

6. Karla.L.Luxner, (1999) “Maternal Infant Nursing care plans”, Mosby

publications

7. Mudaliar. A.L. (2008) “Clinical obstetrics” 9 th edition, Orient longman,

Hyderabad, India.

NET REFERENCES:

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