POSTTERM PREGNANCY or prolonged pregnancy

I. Definition
- ACOG (2004): >= 42 wks (294 days) from 1st day of last menstrual period
- 2 Types: (1) Truly 40 wks past conception
(2) less advanced gestation w/ inaccurate AOG
*postmaturity: fetal syndrome w/ features indicating a pathologically prolonged pregnancy
II. Incidence
3-10%
*Sonography => Inc. precision of AOG estimation vs menstrual dates
*RF:
- prepregnancy BMI >= 25 & nulliparity (Williams)
- 1st birth postterm pregnancy
- Maternal genes
III. Pathophysiology/Complications
- Inc. perinatal mortality: GHPN, prolonged labor, anoxia, malformations
- Labor induction & Inc. caesarean delivery assoc w/ dystocia and fetal distress
- Neonatal ICU, seizues, stillbirth & death
Postmaturity Syndrome
- Wrinkled, peeling skin (associated w/ Dec. vernix caseosa); thin; growth restricted
- assoc w/ oligohydramnios
Placental Dysfunction
- placental apoptosis @41-42 wks
Fetal Distress
- Assoc w/ cord compression due to oligohydramnios
- oligohydramnios continue beyond 38 wks + Inc. meconium
=> Meconium aspiration syndrome
=> reduced successful vaginal delivery (nulliparas)
- oligohydramnios assoc to postterm fetus w/ Inc. risks
Growth restriction
- Inc. stillbirths (delivered @ 42 wks)
*Medical/OB Complications suggests earlier delivery & unwise to continue past 42 wks
IV. Management
- Accurate assessment of AOG & check for RF
- Definite:
a) Labor Induction
- check cervical dilatation (<3cm predictive of successful induction)
- Use of PGE2 to inc. cervical ripening
- Caesarean delivery related to station of vertex
- @ 42 wks: induction has higher caesarean delivery
b) Expectant Mngt/Conservative
- Antepartum assessment

PREMATURE RAPTURE OF MEMBRANES

I. Definition
- ACOG (2007): spontaneous rapture of fetal membranes before 37 completed wks & before labor onset
- Incidence: 6-20%
II. Risk Factors & Causes
1) Intrauterine infection => Major Predisposing event
2) Inc. membrane apoptosis & Inc. protease level (membrane & amnionic)
3) Collagen degradation: ECM @amnion provide membrane strength + amnionic collagen I&II
4) elevated matrix metalloproteinase (MMP) in amnionic fluid
5) low socioeconomic status, low BMI, nutritional deficiencies, cigarette smoking
6) prior PROM
III. Diagnosis
History => 90% accurate
PE => present with leakage of fluid, vaginal discharge, vaginal bleeding, and pelvic pressure
Nitrazine Test
Speculum examination: Pooling of fluid in the vagina or leakage of fluid from the cervix
ferning of the dried fluid under microscopic examination
Fetal Monitoring
Ultrasonographic documentation (gestational age, fetal weight, fetal presentation, and amniotic fluid index)
IV. Risks/Complications
1) Assoc infections: Chorioamnionitis (13-60%), endometritis (2-13%), sepsis (< 1%), and maternal death (1-2 cases per
1000). Complications related to the placenta include abruption (4-12%) and retained placenta or postpartum hemorrhage
requiring uterine curettage (12%) The risk of chorioamnionitis with term PROM has been reported to be less than 10%
and to increase to 40% after 24 hours of PROM.
2) The neonatal risks of expectant management of PROM include infection, placental abruption, fetal distress, fetal
restriction deformities and pulmonary hypoplasia, and fetal/neonatal death.
3) Fetal death does occur in approximately 1% of patients with PROM after viability who have been expectantly managed
4) The primary determinant of neonatal morbidity and mortality is gestational age at delivery (prognosis is good after 32
weeks' gestation)
V. Management
Labor Induction
- vaginal
- caesarean
Expectant Mngt
- fetal assessment
- Cervical cultures including Chlamydia trachomatis and Neisseria gonorrhoeae and anovaginal cultures
for Streptococcus agalactiae should be obtained
- Lab tests
Pharmacotherapy
- National Institute of Child Health and Human Development - Maternal Fetal Medicine Units (NICHD-MFMU): IV
antibiotics => ampicillin 2 g q6h and erythromycin 250 mg q6h
- ORACLE TRIAL: erythromycin alone, amoxicillin clavulanic acid alone, or amoxicillin clavulanic acid in
combination with erythromycin
- The use of corticosteroids to accelerate lung maturity should be considered in all patients with PPROM with a risk of
infant prematurity from 24-34 weeks' gestation:
o The rates of respiratory distress syndrome (RDS), necrotizing enterocolitis, and intraventricular hemorrhage
were all lower when either 12 mg of betamethasone IM was given twice in a 24-hour interval or dexamethasone
6 mg q12h was given for 4 doses
o

ACOG: A single course of corticosteroids is recommended for pregnant women 24-34 weeks' gestation who
are at risk of preterm delivery within 7 days and as early as 23 weeks if delivery is imminent.

A single rescue course of antenatal corticosteroids may be considered if the antecedent treatment was given
more than 2 weeks prior, the gestational age is less than 32 6/7 weeks, and the woman is judged by the
clinician to be likely to give birth within the next week. However, regularly scheduled repeat courses or more
than 2 courses are not recommended.

ASSISTED DELIVERY

FORCEPS DELIVERY
I. Definition
Parts:
1. Branch
2. Each branch:
a. blade
b. shank connect blade & handle
c. lock
d. handle

3. Each blade has 2 curves:

a. Cephalic: fetal head shape
b. Pelvic: axis of birth canals

Types/Classifications:

II. Incidence
- Decreased usage
- Reports of lower maternal/neonatal morbidity assoc w/ instrumental delivery
III. Function & Indications
- For traction and rotation
- Simpson for molded head (nulliparas); Tucker-McLane for rounded head (multiparas)
- Indicated for conditions threatening mother/fetus:
*Heart disease, pulmonary injury, infection, neurological conditions, exhaustion, prolonged 2 nd-stage labor (in
nulliparas: >3H & >2H w/out regional analgesia; multiparas: >2H with & > 1H w/out regional analgesia
*cord prolapsed, premature placental separation, abnormal FHR
- Prerequisites:
1. cervical dilatation
2. ruptured membranes
3. engaged head
4. vertex presentation
5. fetal head position known
6. negative cephalopelvic disproportion
IV. Application/Procedure
- Prep: general/regional analgesia; bladder emptied

V. Complications

VACCUM EXTRACTION
I. Definition
II. Indications and Prerequisites

III. Procedure/Technique

IV. Complications

V. Advantages
FETAL MALPRESENTATION
MALPRESENTATION
Breech:
Complete
Incomplete

PRESENTATION/DIAGNOSIS
Buttocks enter pelvis before head
Knees flexed
One or both hips not flexed and one or
both feet or knees lie below breech
(foot/knee lowermost part of canal)

Frank
Lower extremities flexed at the hips &
extended @ the knees (feet lies near
the head)

Transverse Lie
Occipito-posterior position

Head on one side of the pelvis and the

buttocks in the other
Most common malposition where the
head initially engages normally but
then the occiput rotates posteriorly
rather than anteriorly

MANAGEMENT
Vaginal Delivery:
- full-term and in the frank breech
presentation
- does not show signs of distress while
its heart rate is closely monitored.
- process of labor is smooth and
steady with the cervix widening as the
baby descends.
- The health care provider estimates
that the baby is not too big or the
mothers pelvis too narrow for the baby
to pass safely through the birth canal.
- Anesthesia is available and a
cesarean delivery possible on short
notice
Caesarean Section
close
maternal
monitoring are required

and fetal

The mother may get the urge to push

Occipito-transverse position

Head initially engages correctly but

fails to rotate and remains in a
transverse position

Face Presentations

Face presents for delivery if there is

complete extension of the fetal head

Brow Presentations

Breech Delivery

Fetal head stays between full

extension and full flexion so that the
biggest diameter (the mento-vertex)
presents

before full dilatation but this must be

discouraged. If the head comes into a
face to pubis position then vaginal
delivery is possible as long as there is
a
reasonable
pelvic
size.
Otherwise, forceps or
Caesarean
section may be required.
If the second stage is reached, the
head must be manually rotated with
Kielland's forceps or delivered using
vacuum extraction
Caesarean section w/out forceps
With adequate pelvic size, and rotation
of the head to the mento-anterior
position, vaginal delivery should be
achieved after a long labour
Backwards rotation of the head to a
mento-posterior position requires a
Caesarean section
Unless the head flexes, a vaginal
delivery is not possible, and a
Caesarean section is required

POSTPARTUM HEMORRHAGE
I. Definition
- Loss of >=500 ml of blood after completion of 3rd stage of labor
*late postpartum hemorrhage: bleeding 24h to 12 wks after delivery; assoc w/ placental involution caused by placental
fragment retention
II. Causes
III. Characteristics

May begin before/after placental separation

Moderate bleeding then serious hypovolemia
Failure of pulse & BP to undergo more than moderate alterations until large amounts are lost
If severe hemorrhage in preeclampsia px: immediate lab tests for confirmation & immediate fluid resuscitation
Diagnosis: determine if from lacerations or atony
Lacerations: bleeding in well-contracted uterus; bright red-blood

MEDICAL & SURGICAL COMPLICATIONS IN PREGNANCY

COMPLICATIONS
EFFECTS/DIAGNOSIS

MANAGEMENT

COMPLICATIONS

EFFECTS/DIAGNOSIS

MANAGEMENT

COMPLICATIONS

EFFECTS/DIAGNOSIS

MANAGEMENT

COMPLICATIONS

EFFECTS/DIAGNOSIS

MANAGEMENT

COMPLICATIONS

EFFECTS/DIAGNOSIS

MANAGEMENT