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Post-term Pregnancy Management

Objectives: Low Risk Pregnancy


What is Post-term Pregnancy Why is it worrisome? Risks to Mom and Babe Antenatal monitoring When to Induce How to Induce Induction Timeline

What is PTP and why is it worrisome?


PTP is gestation > 42wks Prevalence is ~10% of all US pregnancies Slightly Increased risk of PTP in women who are primips or a product of PTP 2-3x higher if woman has a prior history of post-term delivery

EDC Dating

Management relies on ACCURATE DATING! Clinical dating by LMP * Early ultrasound: Cochrane & retrospective study* Comparing date by LMP and US: rule* Clinically follow uterine sizing, fundal height, quickening and FHTs for consistency

Risks Mom to Babe

Perinatal (still births and neonatal deaths) Mortality: 2-3/1,000 deliveries at 40wks, doubles at 42 wks and is 4-6x greater at 44wks. Perinatal Morbidity related to fetal growth and uteroplacental insufficiency* Maternal Risks: CPD, labor trauma during delivery, PP hemorrhage, Acute C/S

Antenatal Monitoring

Monitor with the goal of detecting early signs of fetal distress and preventing fetal death Lack of evidence for the benefit of monitoring Option #1: AFI at 41 wks and biweekly NST Option #2: BPP at 41wks AFI >5, BPP 8-10 (normal) 6/8 equivocal Both have high false positive and low false negative rates*

When to Induce: Indications


Urgent / High Priority Non-reassuring status Chorioamnionitis PPROM at 35wks Severe Pre-eclampsia IUGR below 3% IDDM with complications or >40wks Anyone >42wks Medium Priority Maternal medical d/o Fetal malformation Mild pre-eclampsia IUGR below 10% IDDM > 38wks AFI 5-8 Multiple gestation >38wks Hx of demise

Contraindications:

Placenta Previa and Vasa Previous C/S: LTCS or classical Fetal position: breech, transverse, mentum Maternal HTN Polyhydramnios Abnormal FHTs

When to Induce: Research


AAFP 2005: elective induction at 41 wks proposed to reduce rates of adverse fetal and maternal complications. CMPPT largest RCT (1992)* Cochrane Review 19 RCT (2004)* Meta-analysis of 16 RCT (2003)* ACOG: induction at 43wks (1989) but 1997 does not describe an upper GA for expectant management but does rec monitoring by 42 wks. SOGC: routine induction at 41wks (1997) Not all authorities agree in routine intervention

41 wks vs. Expectant Management

Standard of care remains expectant management with antenatal monitoring at 41wks and Induction at 42 wks. 42 wks by expert opinion- as risks to fetus and mom increase with GA Excellent communication with patient is essential!

Non-Medical Labor Stimulators


Hot baths, long walks, spicy food Castrol oil cocktail, enemas Black and blue cohosh Sex, nipple stimulation Stripping the membrane by provider starting at term- Cochrane review: reduced duration of pregnancy and continuing beyond 41 wks

Is the cervix favorable?


Bishop < 6 = Unfavorable so Mechanical Cervial Ripening Stripping of membranes Laminaria Transcervial Foley Catheter- speculum exam, ring forcepts, 30cc foley (14-26 French), sterile saline Monitor FHT for reactivity, insert foley through cervial internal os, RN to inflate and tape to inner thigh- remove within 24hrs

Prostaglandins
Misoprostol (Cytotec) Cost: 25 cents Gel Capsules 25mcg pv Stored at room temp Pt suppine for 30mins, 2 hr NST or until FHT reactive and < 7 ctx in 15 mins Repeat q4hrs max150mcg Cervidil Cost: ~ $200 Capsule with string, 10mg control released, must be stored in freezer Pt suppine for 2hr, continously monitor FHT Repeat q12hrs

Prostaglandins
Misoprostol Risk of Hyerstimulation (>7 ctx in 15mins) Cant remove med!!! Can be pulled out!!! If Hyperstimulation then no more miso or Pitocin! Cant use Oxytocin for 30mins after removal Cervidil Risk of Hyerstimulation Special Indications: Oligo and IUGR

Oxytocin Induction
Bishop score > or equal to 6 = Favorable Goal: >7 ctx per 15mins Low Dose Active Management Start oxytocin at 6 milliunits/min and go up by 6 q20 mins (max 36) If labor is not progressing appropriately, place IUPC and evaluate montevideo units

Induction Timeline

Routine stripping membranes at 37wks 40wks sign consent and educate: increased risk if C/S (2-3x for primip), longer labor, higher chance of instrumented delivery 41 wks: AFI / NST and call induction line 41 wks: NST 41wks: check cervix- calculate bishop

Induction Timeline

Induction Line 386-3286 Info needed: reason for induction, SVE and date done, EDC and method for dates, attending on that day, GBS status, pt home phone number Educate pt on the process (answer the phone) Fax Induction orders and confirm records Triage for cervical ripening the night before planned induction!

Take Home Points


Essential to have accurate dating PTP is associated with increased maternal and fetal risks especially intrauterine fetal death Antenatal monitoring at 41wks: AFI and NST biweekly, or BPP Plan ahead for cervical ripening and scheduling the induction