Podcast
Questions and Answers
What is the range of weeks considered 'full term'?
What is the range of weeks considered 'full term'?
- 39.0 to 46 weeks (correct)
- 39.0 to 40.6 weeks
- 39.0 to 41.6 weeks
- 37.0 to 38.6 weeks
What is the most prevalent cause of prolonged pregnancy, as stated in the content?
What is the most prevalent cause of prolonged pregnancy, as stated in the content?
- Higher BMI
- Incorrect dating (correct)
- Placental sulfatase deficiency
- Genetic predisposition
Which of these factors is NOT listed as increasing the likelihood of a post-term pregnancy?
Which of these factors is NOT listed as increasing the likelihood of a post-term pregnancy?
- Age under 35 (correct)
- First pregnancy
- Previous post-term pregnancy
- BMI greater than 30
What is the significance of using the term "post-dates" when discussing pregnancy management, according to the content?
What is the significance of using the term "post-dates" when discussing pregnancy management, according to the content?
What percentage of births occur after 42 weeks?
What percentage of births occur after 42 weeks?
What is the primary reason for a decrease in the incidence of post-term births in recent years?
What is the primary reason for a decrease in the incidence of post-term births in recent years?
What is the range of weeks considered "late term"?
What is the range of weeks considered "late term"?
Which of the following non-prescribed methods was reported by over 50% of respondents to help induce labor?
Which of the following non-prescribed methods was reported by over 50% of respondents to help induce labor?
What is the primary concern regarding the use of castor oil for inducing labor?
What is the primary concern regarding the use of castor oil for inducing labor?
Which method has a 60% success rate in initiating contractions but is not reliable for inducing labor?
Which method has a 60% success rate in initiating contractions but is not reliable for inducing labor?
Evening Primrose Oil is primarily used for which purpose in labor induction?
Evening Primrose Oil is primarily used for which purpose in labor induction?
What is a common misconception about spicy food when inducing labor?
What is a common misconception about spicy food when inducing labor?
What should be considered critical when determining the timing of labor induction?
What should be considered critical when determining the timing of labor induction?
Which of the following methods is believed to help stimulate the secretion of oxytocin?
Which of the following methods is believed to help stimulate the secretion of oxytocin?
What is a common adverse effect associated with the use of castor oil?
What is a common adverse effect associated with the use of castor oil?
What is a recommended method for nipple stimulation to promote contractions?
What is a recommended method for nipple stimulation to promote contractions?
What does the Bishop score help predict?
What does the Bishop score help predict?
What is the potential effect of using herbal preparations for labor induction?
What is the potential effect of using herbal preparations for labor induction?
What percentage of postpartum patients reported using intercourse as a method to induce labor?
What percentage of postpartum patients reported using intercourse as a method to induce labor?
Why is shared decision-making important when discussing labor induction?
Why is shared decision-making important when discussing labor induction?
What method is theorized to have a positive effect on labor induction but requires more evidence?
What method is theorized to have a positive effect on labor induction but requires more evidence?
Which of the following is NOT a clinical feature of post-maturity syndrome?
Which of the following is NOT a clinical feature of post-maturity syndrome?
What is the primary goal of fetal surveillance in pregnancies beyond 41 weeks?
What is the primary goal of fetal surveillance in pregnancies beyond 41 weeks?
Which fetal surveillance method is recommended to include an evaluation of amniotic fluid?
Which fetal surveillance method is recommended to include an evaluation of amniotic fluid?
When is membrane sweeping or stripping typically performed?
When is membrane sweeping or stripping typically performed?
What is a theoretical risk associated with membrane sweeping?
What is a theoretical risk associated with membrane sweeping?
Which of the following is TRUE about membrane sweeping for GBS positive patients?
Which of the following is TRUE about membrane sweeping for GBS positive patients?
What is a possible outcome of membrane sweeping?
What is a possible outcome of membrane sweeping?
Which of the following is NOT a potential placental issue that can decrease oxygen exchange?
Which of the following is NOT a potential placental issue that can decrease oxygen exchange?
How often is fetal surveillance typically performed at 41 weeks?
How often is fetal surveillance typically performed at 41 weeks?
According to the content, what is the recommended approach to managing prolonged pregnancy at 41-42 weeks?
According to the content, what is the recommended approach to managing prolonged pregnancy at 41-42 weeks?
What is the term used to describe a baby born at 39 or 40 weeks with clinical signs of placental dysfunction?
What is the term used to describe a baby born at 39 or 40 weeks with clinical signs of placental dysfunction?
What are some of the clinical features of post-maturity syndrome?
What are some of the clinical features of post-maturity syndrome?
What is the recommended approach to managing prolonged pregnancy at 42 weeks?
What is the recommended approach to managing prolonged pregnancy at 42 weeks?
Which of the following is NOT a potential complication of prolonged pregnancy?
Which of the following is NOT a potential complication of prolonged pregnancy?
What is the typical range of weeks for a pregnancy considered prolonged?
What is the typical range of weeks for a pregnancy considered prolonged?
Which of the following scenarios would you recommend for an induction of labor?
Which of the following scenarios would you recommend for an induction of labor?
What is the primary outcome assessed in the ARRIVE trial?
What is the primary outcome assessed in the ARRIVE trial?
What is a valid indication for cervical ripening with prostaglandins?
What is a valid indication for cervical ripening with prostaglandins?
What is NOT a valid indication for labor induction with Pitocin?
What is NOT a valid indication for labor induction with Pitocin?
Which of the following is NOT a method commonly used for cervical ripening in an outpatient setting?
Which of the following is NOT a method commonly used for cervical ripening in an outpatient setting?
How does the ARRIVE trial suggest elective induction of labor at 39 weeks impact the need for cesarean birth?
How does the ARRIVE trial suggest elective induction of labor at 39 weeks impact the need for cesarean birth?
What aspect of the ARRIVE trial results requires caution when interpreting the findings?
What aspect of the ARRIVE trial results requires caution when interpreting the findings?
What does the term "unfavorable cervix" refer to?
What does the term "unfavorable cervix" refer to?
What is the primary concern associated with an induction of labor at 42 weeks?
What is the primary concern associated with an induction of labor at 42 weeks?
What is the main concern about using synthetic osmotic dilators for cervical ripening?
What is the main concern about using synthetic osmotic dilators for cervical ripening?
What is the primary difference between cervical ripening and labor induction?
What is the primary difference between cervical ripening and labor induction?
What is a bishop score?
What is a bishop score?
What is the primary reason why some individuals may decline induction of labor?
What is the primary reason why some individuals may decline induction of labor?
What is the role of a midwife in managing a patient who declines an induction of labor at 42 weeks?
What is the role of a midwife in managing a patient who declines an induction of labor at 42 weeks?
What is the significance of the statement "the uterus and cervix are one contiguous structure, however, the cervical composition is different than that of the uterus"?
What is the significance of the statement "the uterus and cervix are one contiguous structure, however, the cervical composition is different than that of the uterus"?
What is the primary reason to avoid elective induction of labor at 39 weeks?
What is the primary reason to avoid elective induction of labor at 39 weeks?
What is the primary mechanism by which the HPA axis influences labor?
What is the primary mechanism by which the HPA axis influences labor?
What is the relationship between placental sulfatase deficiency and pregnancy duration?
What is the relationship between placental sulfatase deficiency and pregnancy duration?
Which of the following is a potential consequence of placental aging in prolonged pregnancies?
Which of the following is a potential consequence of placental aging in prolonged pregnancies?
What is the main reason for recommending delivery by 42 weeks gestation?
What is the main reason for recommending delivery by 42 weeks gestation?
Which of the following is NOT considered a potential risk associated with post-term pregnancies?
Which of the following is NOT considered a potential risk associated with post-term pregnancies?
What is the primary reason for the increased risk of meconium aspiration in post-term pregnancies?
What is the primary reason for the increased risk of meconium aspiration in post-term pregnancies?
What is the primary role of progesterone in regulating labor?
What is the primary role of progesterone in regulating labor?
Which of the following is a common physical finding observed in placentas from post-term pregnancies?
Which of the following is a common physical finding observed in placentas from post-term pregnancies?
How does the lack of a pituitary gland in anencephalic fetuses affect labor?
How does the lack of a pituitary gland in anencephalic fetuses affect labor?
Which of the following is NOT a potential risk associated with macrosomia?
Which of the following is NOT a potential risk associated with macrosomia?
Based on the available data, what is the recommended approach to managing pregnancies beyond 41 weeks?
Based on the available data, what is the recommended approach to managing pregnancies beyond 41 weeks?
What is the primary factor influencing the timing of labor in pregnancies with placental sulfatase deficiency?
What is the primary factor influencing the timing of labor in pregnancies with placental sulfatase deficiency?
Which of the following is a potential consequence of prolonged pregnancies that is NOT directly related to placental aging?
Which of the following is a potential consequence of prolonged pregnancies that is NOT directly related to placental aging?
What is the main reason for the increased risk of stillbirth in post-term pregnancies?
What is the main reason for the increased risk of stillbirth in post-term pregnancies?
Which of the following statements accurately describes the relationship between the study of post-term pregnancies and the timing of labor?
Which of the following statements accurately describes the relationship between the study of post-term pregnancies and the timing of labor?
What is the incidence of prolonged pregnancy higher among?
What is the incidence of prolonged pregnancy higher among?
What are the risks of prolonged pregnancy most associated with?
What are the risks of prolonged pregnancy most associated with?
What are maternal risks of prolonged pregnancy?
What are maternal risks of prolonged pregnancy?
What can result from exposure to malnutrition and decreased body fat in an infant, identified after birth via clinical features?
What can result from exposure to malnutrition and decreased body fat in an infant, identified after birth via clinical features?
What are clinical features of fetal postmaturity syndrome?
What are clinical features of fetal postmaturity syndrome?
What is there an increased incidence of with newborns with fetal postmaturity syndrome?
What is there an increased incidence of with newborns with fetal postmaturity syndrome?
What is the etiology (in order) of post-term labor onset?
What is the etiology (in order) of post-term labor onset?
As the placenta ages and dysfunction occurs, what does intervillous hemorrhagic infarcts, thickening and degradation of the basal membrane vessels lead to?
As the placenta ages and dysfunction occurs, what does intervillous hemorrhagic infarcts, thickening and degradation of the basal membrane vessels lead to?
What theorized factor may contribute to prolonged pregnancy, an enzyme defect where there is decreased estrogen in the male fetus (X-linked)?
What theorized factor may contribute to prolonged pregnancy, an enzyme defect where there is decreased estrogen in the male fetus (X-linked)?
In the absence of complications, when should antenatal fetal surveillance begin? How often should antenatal fetal surveillance occur? What antenatal fetal surveillance may be used?
In the absence of complications, when should antenatal fetal surveillance begin? How often should antenatal fetal surveillance occur? What antenatal fetal surveillance may be used?
What is an ideal component to antenatal fetal surveillance due to the risk of oligohydramnios?
What is an ideal component to antenatal fetal surveillance due to the risk of oligohydramnios?
When should a Bishop's score be considered? At 42 weeks, what percent of pregnant individuals will have an unfavorable cervix?
When should a Bishop's score be considered? At 42 weeks, what percent of pregnant individuals will have an unfavorable cervix?
When should an induction of labor be considered? When should an induction of labor be recommended?
When should an induction of labor be considered? When should an induction of labor be recommended?
What is the cervix made up of?
What is the cervix made up of?
What Bishop's score is correlated with successful induction? What Bishop's score is correlated with induction success similar to spontaneous labor and delivery?
What Bishop's score is correlated with successful induction? What Bishop's score is correlated with induction success similar to spontaneous labor and delivery?
If nipple stimulation is used in prolonged pregnancy, how should a patient perform?
If nipple stimulation is used in prolonged pregnancy, how should a patient perform?
What does nipple stimulation assist with?
What does nipple stimulation assist with?
What is the evidence for blue/black cohash in prolonged labor?
What is the evidence for blue/black cohash in prolonged labor?
What is evening primrose oil?
What is evening primrose oil?
What does evening primrose oil promote?
What does evening primrose oil promote?
What do some studies show evidence of evening primrose oil resulting in?
What do some studies show evidence of evening primrose oil resulting in?
At what EGA can membrane sweep/stripping be performed? How dilated must a patient be? What is the recommended amount of membrane sweeps/stripping?
At what EGA can membrane sweep/stripping be performed? How dilated must a patient be? What is the recommended amount of membrane sweeps/stripping?
What are potential concerns with membrane sweeps/stripping?
What are potential concerns with membrane sweeps/stripping?
What are cervical ripening agents?
What are cervical ripening agents?
What are indications for cervical ripening with prostaglandins (dinoprostone, misoprostol)?
What are indications for cervical ripening with prostaglandins (dinoprostone, misoprostol)?
What medication is used for labor induction/stimulate contractions?
What medication is used for labor induction/stimulate contractions?
What are indications for labor induction with Pitocin (oxytocin)?
What are indications for labor induction with Pitocin (oxytocin)?
According to the ARRIVE trial, when should induction be offered to patients?
According to the ARRIVE trial, when should induction be offered to patients?
What is the early effect of fetal oxygenation decreasing, and how long can it persist?
What is the early effect of fetal oxygenation decreasing, and how long can it persist?
What effect of fetal oxygenation decreasing leads to risk to critical organs, risk for head sparing growth restriction and results in the release of stress hormones (norepinephrine and cortisol)?
What effect of fetal oxygenation decreasing leads to risk to critical organs, risk for head sparing growth restriction and results in the release of stress hormones (norepinephrine and cortisol)?
What is the result of fetal oxygenation decreasing which results in central organ failure?
What is the result of fetal oxygenation decreasing which results in central organ failure?
What are biophysical characteristics which show signs of fetal well-being?
What are biophysical characteristics which show signs of fetal well-being?
What are measures of placental function?
What are measures of placental function?
What is based on the healthy and well oxygenated fetus exhibiting characteristic movement throughout the day?
What is based on the healthy and well oxygenated fetus exhibiting characteristic movement throughout the day?
What is fetal movement/kick counting an indicator of?
What is fetal movement/kick counting an indicator of?
When can regular fetal movement be expected?
When can regular fetal movement be expected?
What is routine fetal kick counting not recommended in?
What is routine fetal kick counting not recommended in?
What circumstances indicate for a patient to alert their provider regarding fetal movement/kick counts?
What circumstances indicate for a patient to alert their provider regarding fetal movement/kick counts?
What should a fetus be evaluated with in the case that a mother reports decreased fetal movement?
What should a fetus be evaluated with in the case that a mother reports decreased fetal movement?
What fetal monitoring technique is based off a healthy and well oxygenated fetus showing heart rate patterns associated with their own movement?
What fetal monitoring technique is based off a healthy and well oxygenated fetus showing heart rate patterns associated with their own movement?
How is a patient positioned for an NST, and how long will the NST be performed?
How is a patient positioned for an NST, and how long will the NST be performed?
What does heart rate variability indicate maturity of?
What does heart rate variability indicate maturity of?
What is the best predictor of fetal oxygenation based on an NST?
What is the best predictor of fetal oxygenation based on an NST?
What are size and duration of reactive heart rate decelerations based on?
What are size and duration of reactive heart rate decelerations based on?
What is the specificity and sensitivity of an NST?
What is the specificity and sensitivity of an NST?
When is an NST most predictive?
When is an NST most predictive?
What fetal monitoring technique is based on a healthy and well oxygenated fetus being able to maintain a heart rate that is stable despite contractions?
What fetal monitoring technique is based on a healthy and well oxygenated fetus being able to maintain a heart rate that is stable despite contractions?
What is the contraction criteria during a CST?
What is the contraction criteria during a CST?
What position will the patient be in during a CST?
What position will the patient be in during a CST?
What should occur to a FHR during a CST?
What should occur to a FHR during a CST?
During a CST, what indicates a loss of fetal reserves and resiliency?
During a CST, what indicates a loss of fetal reserves and resiliency?
What is the sensitivity and specificity of a CST?
What is the sensitivity and specificity of a CST?
What result is wanted for a CST?
What result is wanted for a CST?
What does a negative CST provide?
What does a negative CST provide?
What fetal monitoring technique is more often used during labors where intermittent auscultation is being used to detail audible FHR accels?
What fetal monitoring technique is more often used during labors where intermittent auscultation is being used to detail audible FHR accels?
What fetal monitoring technique is based on a healthy and well oxygenated fetus behaving in characteristic ways and showing evidence of normal CNS activity?
What fetal monitoring technique is based on a healthy and well oxygenated fetus behaving in characteristic ways and showing evidence of normal CNS activity?
What are the components of a biophysical profile?
What are the components of a biophysical profile?
What BPP score is reassuring of good oxygenation?
What BPP score is reassuring of good oxygenation?
What is better for identifying decreased oxygenation than an NST or CST?
What is better for identifying decreased oxygenation than an NST or CST?
For a BPP, what positive predictor values will indicate stillbirth risk?
For a BPP, what positive predictor values will indicate stillbirth risk?
What ultrasound technique for fetal monitoring will use normative data to compare expected fluid amounts based on gestational age?
What ultrasound technique for fetal monitoring will use normative data to compare expected fluid amounts based on gestational age?
Based on pregnancy physiology, when is there a reduction in AFV?
Based on pregnancy physiology, when is there a reduction in AFV?
What assessment of amniotic fluid volume uses the largest cord-free pocket of fluid in each of 4 maternal quadrants, totaled for a calculated volume?
What assessment of amniotic fluid volume uses the largest cord-free pocket of fluid in each of 4 maternal quadrants, totaled for a calculated volume?
What assessment of amniotic fluid volume uses the greatest dimension of the largest pocket of cord-free fluid, regardless of the fluid location?
What assessment of amniotic fluid volume uses the greatest dimension of the largest pocket of cord-free fluid, regardless of the fluid location?
What does lower AFV increase the risk for?
What does lower AFV increase the risk for?
What fetal monitoring technique is used to detect the speed and direction of blood flow velocity in utero placental and intracranial vessels?
What fetal monitoring technique is used to detect the speed and direction of blood flow velocity in utero placental and intracranial vessels?
How is Doppler velocimetry done?
How is Doppler velocimetry done?
What is the EGA needed to perform Doppler velocimetry?
What is the EGA needed to perform Doppler velocimetry?
What are maternal conditions that Doppler velocimetry may be warranted in?
What are maternal conditions that Doppler velocimetry may be warranted in?
What are the 2 most common vessels examined with Doppler velocimetry?
What are the 2 most common vessels examined with Doppler velocimetry?
What do arterial Doppler indices indicate, and what is the ideal value?
What do arterial Doppler indices indicate, and what is the ideal value?
What is a higher S:D ratio for Doppler velocimetry associated with?
What is a higher S:D ratio for Doppler velocimetry associated with?
What can occur with a rising S:D ratio?
What can occur with a rising S:D ratio?
What is used for fetal surveillance which samples cord blood via venopuncture on the umbilical cord for fetal blood?
What is used for fetal surveillance which samples cord blood via venopuncture on the umbilical cord for fetal blood?
What is percutaneous umbilical blood sampling used for?
What is percutaneous umbilical blood sampling used for?
What fetal monitoring technique withdraws a sample of amniotic fluid and tests for biomarkers indicative of fetal lung maturity?
What fetal monitoring technique withdraws a sample of amniotic fluid and tests for biomarkers indicative of fetal lung maturity?
What biomarkers from an amniocentesis for fetal lung maturity indicate fetal lung maturity?
What biomarkers from an amniocentesis for fetal lung maturity indicate fetal lung maturity?
According to ACOG, what are NST and BPP considered for predicting the value of stillbirth?
According to ACOG, what are NST and BPP considered for predicting the value of stillbirth?
What are indicators of acute asphyxia on a BPP?
What are indicators of acute asphyxia on a BPP?
What is an indicator of chronic asphyxia on BPP?
What is an indicator of chronic asphyxia on BPP?
Flashcards
Early Term
Early Term
Refers to pregnancies from 37.0 to 38.6 weeks.
Full Term
Full Term
Defined as the duration from 39.0 to 40.6 weeks of pregnancy.
Late Term
Late Term
Refers to pregnancies completing from 41.0 to 41.6 weeks.
Post Term
Post Term
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Prolonged Pregnancy
Prolonged Pregnancy
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Incorrect Dating
Incorrect Dating
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Post Dates
Post Dates
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Genetic Influences
Genetic Influences
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X Linked Recessive Disorder
X Linked Recessive Disorder
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Anencephaly
Anencephaly
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HPA Axis
HPA Axis
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Corticotropin Release
Corticotropin Release
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Prostaglandins
Prostaglandins
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Macrosomia
Macrosomia
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Oligohydramnios
Oligohydramnios
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Placental Senescence
Placental Senescence
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Stillbirth Risk
Stillbirth Risk
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Fetal Cardiac Function
Fetal Cardiac Function
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Induction of Labor
Induction of Labor
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Meconium Aspiration
Meconium Aspiration
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Uterine Myometrium
Uterine Myometrium
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Doppler Studies
Doppler Studies
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Elder Studies
Elder Studies
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Intervillous Infarcts
Intervillous Infarcts
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Fetal Hemorrhage
Fetal Hemorrhage
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True Knot
True Knot
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Wharton's Jelly
Wharton's Jelly
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Postmaturity Syndrome
Postmaturity Syndrome
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Clinical Features of Postmaturity
Clinical Features of Postmaturity
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Risk of Oligohydramnios
Risk of Oligohydramnios
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Fetal Surveillance
Fetal Surveillance
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Membrane Sweeping
Membrane Sweeping
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Consent in Membrane Sweeping
Consent in Membrane Sweeping
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Biophysical Profile (BPP)
Biophysical Profile (BPP)
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Cervical Ripening Techniques
Cervical Ripening Techniques
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Maternal Risks Beyond 42 Weeks
Maternal Risks Beyond 42 Weeks
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Accidental Rupture of Membranes
Accidental Rupture of Membranes
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Bishop Score
Bishop Score
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Prosthetic Method
Prosthetic Method
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Mechanical Dilation
Mechanical Dilation
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Foley Balloon Catheter
Foley Balloon Catheter
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Laminaria
Laminaria
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Synthetic Osmotic Dilators
Synthetic Osmotic Dilators
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Arrive Trial
Arrive Trial
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Cesarean Delivery Rate
Cesarean Delivery Rate
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Perinatal Mortality
Perinatal Mortality
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Low Risk Pregnancy
Low Risk Pregnancy
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Induction Counsel
Induction Counsel
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Non-Reactive NST
Non-Reactive NST
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Patient Autonomy
Patient Autonomy
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Eleven (G3P1011)
Eleven (G3P1011)
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Non-prescribed methods of labor induction
Non-prescribed methods of labor induction
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Walking to induce labor
Walking to induce labor
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Intercourse for labor induction
Intercourse for labor induction
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Spicy food and labor
Spicy food and labor
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Nipple stimulation's effect on labor
Nipple stimulation's effect on labor
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Castor oil's role
Castor oil's role
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Evening Primrose Oil
Evening Primrose Oil
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Acupuncture for labor
Acupuncture for labor
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Risks of exceeding 42 weeks
Risks of exceeding 42 weeks
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Prostaglandins in semen
Prostaglandins in semen
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Herbal preparations for labor
Herbal preparations for labor
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Laxatives' role in labor
Laxatives' role in labor
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Risks associated with black and blue cohash
Risks associated with black and blue cohash
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Nulliparous
Nulliparous
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Fetal macrosomnia
Fetal macrosomnia
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Maternal risks of prolonged pregnancy
Maternal risks of prolonged pregnancy
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Fetal risks of prolonged pregnancy
Fetal risks of prolonged pregnancy
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Fetal postmaturity syndrome
Fetal postmaturity syndrome
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Clinical features of fetal postmaturity syndrome
Clinical features of fetal postmaturity syndrome
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Induction of labor considerations
Induction of labor considerations
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Cervical ripening agents
Cervical ripening agents
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Fetal heart monitoring techniques
Fetal heart monitoring techniques
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Doppler velocimetry
Doppler velocimetry
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Positive CST results
Positive CST results
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Amniotic fluid index
Amniotic fluid index
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Components of BPP
Components of BPP
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Meconium aspiration syndrome
Meconium aspiration syndrome
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Fetal oxygenation decrease
Fetal oxygenation decrease
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Kick counts
Kick counts
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Clinical features of meconium aspiration
Clinical features of meconium aspiration
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Percutaneous umbilical blood sampling
Percutaneous umbilical blood sampling
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Amniocentesis for lung maturity
Amniocentesis for lung maturity
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Indications for fetal monitoring
Indications for fetal monitoring
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Maternal factors influencing pregnancy
Maternal factors influencing pregnancy
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Fetal surveillance goals
Fetal surveillance goals
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Fetal heart rate response to movement
Fetal heart rate response to movement
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Nipple stimulation for contractions
Nipple stimulation for contractions
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Labor induction types
Labor induction types
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Study Notes
Prolonged Pregnancy Management
- Term: 37 weeks and beyond. Early term (37.0-38.6 weeks), Full term (39.0-40.6 weeks), Late term (41.0-41.6 weeks), Post term (294 days/42 weeks). "Post dates" is irrelevant; it just means past the due date.
- Increased Risk Factors: Nulliparous pregnancies, women over 35, history of prior post-term pregnancies, genetic predisposition, obesity. Incidence of post-term birth has decreased.
- Maternal Risks: perineal trauma, postpartum hemorrhage (pp hemorrage), operative vaginal or cesarean birth (higher risk), infections.
Causes of Prolonged Pregnancy
- Inaccurate Dating: Irregular cycles, poor recall of dates, long cycles, PCOS, late entry to care. Early ultrasounds are vital for accurate dating.
- Other Factors: Placental sulfatase deficiency (rare X-linked recessive disorder, low estrogen in male fetuses), fetal adrenal insufficiency, anencephaly. (Anencephaly lack of pituitary stops HPA axis function, preventing spontaneous labor.) Decreased production and storage of prostaglandin precursors, and/or decreased stimulation to form oxytocin receptors in myometrium, contribute.
Mechanisms of Normal Labor
- HPA Axis: Corticotropin releasing hormone (CRH) from fetal brain stimulates adrenocorticotropic hormone (ACTH) from the pituitary, then cortisol from adrenal gland. This increases prostaglandins & estrogens, decreasing progesterone and triggering uterine contractions.
- Post-Term Labor Onset Etiology: Placental estrogen deficiency OR decreased prostaglandin release, decreased production and storage of prostaglandin precursors, and/or decreased stimulation to form oxytocin receptors in myometrium.
Fetal Risks: Late/Post-Term Pregnancies
- No Significant Increase in Mortality: Studies don't generally show increased intrauterine fetal death or neonatal death at 41 weeks compared to 39-40 weeks, but increased morbidity has been noted.
- More Uterine Deaths: Many more fetal deaths occur in utero in the 37-42 week range and before, compared to post-term. Not all studies show this
- Placental Aging: Placental dysfunction is a concern, with risks of macrosomia, placental insufficiency, and inducing labor when uterus isn't ready—resulting in operative vaginal delivery/ cesarean delivery.
- Meconium Staining: Risk of meconium stained amniotic fluid (30% vs 19% full term risk) with higher risk of meconium aspiration.
- Oligohydramnios: low amniotic fluid, pathogenesis uncertain but linked to fetal hypoxemia, blood flow redistribution (to brain) and renal hypoperfusion impacting urine production (which makes amniotic fluid), and placental senescence (aging).
- Doppler studies: no deterioration in cardiac output in post-term fetuses
- Stillbirths: Stillbirth rates increase from 0.11/1,000 at 37 weeks to 1.78/1,000 at 41 weeks, and 3.13/1,000 at 42 weeks, signifying starting fetal monitoring at 41 weeks and inducing at 42 weeks, Increased risk of stillbirth due to cord impingement.
- Fetal Risks (additional): Fetal macrosomnia, placental insufficiency, labor induction w/o ripened cervix, labor dystocia (shoulder), increased perinatal morbidity in 41st week , meconium stained amniotic fluid, oligohydraminos (lower apgars, NICU, fetal distress, decreased LV CO), placental dysfunction, stillbirth.
Post Maturity Syndrome
- Clinical Syndrome: Wasting of subcutaneous tissue, meconium staining of skin and nails, wrinkles, long nails, calcified skull, delayed fetal growth.
- Diagnosis: Postnatal diagnosis, commonly impacting 10-20% of post-term fetuses (or 10-30% of prolonged pregnancies) affected by issues like fetal malnutrition.
- Increased Risk: Higher risk of the complications mentioned in earlier sections, including meconium aspiration, oligohydramnios, umbilical cord compression, abnormal FHR patterns, hypoglycemia.
Prolonged Pregnancy Management: 41-42 Weeks
- Expectant Management: Goal is minimizing IUFD. ACOG recommends initiating fetal surveillance at 41 weeks but doesn't specify methods or frequency.
- Monitoring: General practice is twice weekly monitoring at 41 weeks with NST, BPP, modified BPP. Include amniotic fluid evaluation (AFV) /amniotic fluid index (AF), due to the risk of oligohydramnios.
- Membrane Sweeping: Mechanical technique to stimulate cervical ripening, can be done after 38 weeks; and only if the cervix is dilated at least 1 cm, should avoid rupturing membranes and consider risks with GBS+ patients.
- Induction of Labor: Should be considered after 41 weeks or if a patient's cervix is not ready, or if the fetus shows deterioration signals. Considerations for this decision include the patient's preferences, birth plan, Bishop score, and social support structures like a partner.
Induction of Labor
- Bishop Score: Pre-labor scoring system to predict induction success. Scores higher than 6 are likely to result in a successful induction; >8 suggests a favorable cervix. Most patients past 42 weeks are unlikely to have a favorable cervix, as 80% of 42-week pregnancies will have an unfavorable cervix.
- Cervical Ripening Methods (prior to Pitocin): Cook catheters, Foley balloon catheters, Laminaria, Synthetic osmotic dilators.
- Pitocin Induction: Suggested for bishop score >5 or rupture of membranes.
The ARIVED Trial
- Elective Induction at 39 Weeks: The trial suggests that elective induction of low-risk pregnancies at 39 weeks may significantly reduce the need for Cesarean delivery compared to expectant management (18.6% versus 22.2% reduced Cesarean deliveries) and reduced perinatal mortality and morbidity.
Patient Scenarios
- Induction Considerations: Patient factors (e.g., strong social needs, high bishop score, and/or non-reactive NST) need to be considered.
- Management Approaches: Consideration to expectant management, fetal surveillance, membrane sweeping, or induction will vary according to the patient.
- Documentation: Crucial to document all discussions and decisions made with patients.
Fetal Monitoring Techniques
- Fetal Movement/Kick Counts: Based on healthy and well-oxygenated fetuses exhibiting characteristic movement throughout the day; indicators of CNS activity and muscle tone. (should be >24 weeks, and not recommended w/ risk factors). Unusual decrease, <10 movements in 12 hours for 2 consecutive days or no movement in 12 hours on a single day, needs provider consultation. Evaluation with cardiotocographic or ultrasound assessment (NST, CST).
- Non-Stress Test (NST): Based on a well-oxygenated fetus showing heart rate patterns associated with its own movement. Patient positioned semi-recumbent side-lying; 20 minutes (extendible). Moderate variability (5-25 bpm) is the best predictor of fetal oxygenation. Low false negative, high false positive (non-reactive NST = not specific for poor fetal oxygenation).
- Contraction Stress Test (CST): Based on a healthy fetus maintaining a stable heart rate despite contractions. Patient positioned semi-recumbent side-lying. 3 contractions in 10 minutes at least 40-60 seconds in duration are required. FHR should remain moderate and not drop during/after contractions. Loss of variability, decelerations beyond end of contraction indicate fetal distress. Low false negative rate, high false positive rate. Negative result is preferred; higher reassurance than a NST.
- Auscultated Acceleration Test: Used during labors where intermittent auscultation details audible FHR accelerations.
- Biophysical Profile (BPP): Based on a healthy and well-oxygenated fetus. Components include body and limb movement, fetal breathing movement, amniotic fluid volume. Score of 8/8 or 10/10 is reassuring; higher score = lower risk. Low score = higher risk.
- Amniotic Fluid Volume Assessment: Ultrasound technique to compare expected fluid amounts based on gestational age. Reduction in AFV occurs in the third trimester.
- Amniotic Fluid Index (AF/AFV): Uses 4 pocket measures (largest fluid pocket in each maternal quadrant),
- Maximum/Deepest Ventricular Pocket (AFV): Uses the greatest dimension of the largest pocket, regardless of location. Lower AFV increases risk of stillbirth due to cord impingement.
- Doppler Velocimetry: Used to detect blood flow velocity in utero, placental and intracranial vessels. Transabdominal or transvaginal ultrasound. Can be warranted in mothers with hypertensive disorders, diabetes, heart disease; and fetuses with growth restriction, cardiac anomalies or if placental conditions cause concern. The umbilical artery and fetal arterial circulation (MCA: middle cerebral artery) are frequently examined, and the S:D ratio is measured (<3.0). A higher S:D ratio indicates poor placental perfusion and abnormal fetal growth. Absent diastolic flow signifies increasing issues.
- Percutaneous Umbilical Blood Sampling: Samples cord blood for fetal blood gases, anemia, bleeding disorders, hemoglobinopathies, infection, genetic studies, or for fetal therapy (blood transfusion).
- Amniocentesis: Withdraws amniotic fluid to test for biomarkers of fetal lung maturity (lecithin and sphingomyelin ratio: L:S ratio > 2.0 and phosphatidyglycerol: present)
- Nipple Stimulation: A patient can perform 30 minutes on one side (repeat on the other side) for a maximum of 2 rounds (2hrs total).
Additional Information
- Nipple stimulation can produce contractions (60%).
- Evidence for blue/black cohash in prolonged labor is not recommended.
- Evening primrose oil is a prostaglandin precursor. Promotes cervical ripening, and some studies show a possibility for ROM/PROM as a result.
- Membrane sweep/stripping can be performed at > 38 weeks, with cervix dilated at least 1 cm; and there is no recommended number of sweeps. (Potential concerns include accidental ROM, GBS + patients, and spotting discussion.)
- Cervical ripening agents include misoprostol (Cytotec) and dinoprostone (Cervidil). Indication is for bishops score <5, membranes intact, and no regular contractions.
- Oxytocin (Pitocin) is used for labor induction/stimulation; indications are for bishops score >5 or ROM. Elective induction of low risk pregnancies should be considered for > 39 weeks (per ARIVED trial).
- As placental function declines, intervillous hemorrhagic infarcts, and thickening/degeneration of the basal membrane vessels lead to decreased diffusion of oxygen.
- Hypoxemia (weeks to days), Hypoxia (days to hours), and Asphyxia (hours to minutes) are progressively adverse effects of decreased fetal oxygenation.
- Biophysical characteristics indicating fetal well-being include heart rate/activity, fetal movement, neurologic state, pulmonary development, and hematologic state.
- Measures of placental function include amniotic fluid volume, placental tissue aging/grading, and umbilical cord vessel function.
- According to ACOG, NST and BPP are considered equivalent predictors for stillbirth risk.
- Indicators of acute asphyxia in a BPP include fetal breathing movements, fetal movements, and fetal tone; chronic asphyxia is indicated by amniotic fluid volume.
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