stages These stages where described by Clifford (1954) and consist of 3 stages: 1 - wrinkled, peeling skin, with thin body 2 - stage 1 and fetal distress, meconium present 3 - stage 1 & 2, findings with meconium stained skin or nails
The Clifford criteria has been more recently modified to describe dysmaturity, which is defined as mild -only skin and nail findings, or advanced -skin, nail findings and loss of subcutaneous fat with meconium staining.
What are the risks of a postdate pregnancy? Most babies born postdate are healthy. In some, there are risks to the fetus and newborn baby. These risks include: The placenta may not work well. The amount of fluid around the baby may decrease. This may cause the umbilical cord to become compressed before or during labor. The fetus grows larger which may cause some problems with birthing the baby. The fetus may show signs of distress in labor
Because of postdate or distress, the fetus may pass its stool while still inside the mother. If this occurs, there is a risk that the baby may develop a severe, perhaps life-threatening illness (meconium aspiration syndrome). The fetus or newborn may have postmaturity syndrome. Babies with this syndrome can have loss of fat, wrinkled and peeling skin, long nails, low blood sugar, and are at risk of stillbirth. There may be a greater chance of cesarean birth. Cesarean births can increase risks to the mother, such as infection, bleeding, and a longer recovery time
What tests can be used to assess my fetus as I approach postdate? If you go beyond 41½ weeks, some tests are advised to assess your baby’s well-being Fetal Kick Counts: This is an old and simple method and involves counting the baby’s movements once or twice a day. It is normal for the baby to have 8 to 10 distinct movements in 2 hours. You can begin doing this at home daily.
Nonstress Test (NST) combined with Amniotic Fluid Index (AFI): For the NST, a fetal monitor is used to check the heart rate response of the baby. The heart rate of a healthy fetus will increase with fetal movements. The AFI is an ultrasound which measures the amount of amniotic fluid present. This gives us an idea of how well the placenta is working. Both of these tests combined are called a Modified Biophysical Profile and may be done two times per week.
Contraction stress test (CST) IV oxytocin or nipple stimulation until patient has 3 contractions in 10 minutes negative - no decelerations positive - repetitive late decelerations or variable decelerations suspicious - isolated late or variable decelerations Biophysical profile (BPP) reactive NST, fetal breathing, extension - flexion, gross body movement, 2 cm X 2 cm pocket; 2 points for the presence of each variable
Cont… Doppler multiple studies assessing almost any vessel suggest that Doppler is not helpful even using absent end diastolic flow. ACOG continues to consider Doppler investigational
Management What is not controversial regarding the management of the postdates patient is: Do not allow any pregnancy with other high risk factors to go postdates - perinatal morbidity is too high. If the post-term patient has a favorable cervix (Bishop's score > 6, then induction of labor is the preferred management.
Recommendations for management of the postdates pregnancy:- At 41.5 weeks begin antenatal testing (NST and amniotic fluid index - AFI), cervical exam If any testing is abnormal (AFI < = 5.0 cm, NST with any decelerations) induce If cervix is favorable (can rupture membranes or Bishops >= 6) induce
If macrosomia is suspected with EFW >= 4500 grams either induce or obtain ultrasound to confirm and induce Remaining patients are followed semiweekly with NST, fluid check, and cervical exam and if any of the above occur the patient is induced If not in labor by 43 weeks induce All patients are given kick count instructions to perform daily.
What are our choices? If the results of these tests are normal, you have the choice of waiting until labor starts on its own or having labor induced. Labor can be induced by
Prostaglandins: This is a hormone that is applied near the cervix as a gel or timed release insert. Its purpose is to get the cervix ready for labor by helping it soften and thin. Pitocin: Medicine is given through an IV to cause the uterus to contract. Breaking the bag of waters: This is called amniotomy. If the cervix is ready and the baby’s head is low enough, this may be done to induce labor in women who have had a baby before.