Prolonged pregnancy Prolonged pregnancy Post term pregnancy = prolonged pregnancy Post term pregnancy = prolonged pregnancy - post maturity : describe neonate that have specific characteristics as long nails,loose skin,peeling of epidermis. - post maturity : describe neonate that have specific characteristics as long nails,loose skin,peeling of epidermis.

Prolonged pregnancy increase risk of perinatal morbidity & mortality rate Prolonged pregnancy increase risk of perinatal morbidity & mortality rate.*definition of prolonged pregnancy : as pregnancy equal to or more than 42 weeks or 294 days from the 1st day of LMP..*definition of prolonged pregnancy : as pregnancy equal to or more than 42 weeks or 294 days from the 1st day of LMP.

* associated risks of prolonged pregnancy : 1- macrosomic infant ( shoulder dystocia ) 1- macrosomic infant ( shoulder dystocia ) 2-genital tract trauma. 2-genital tract trauma. 3-post partum hemorrhage. 3-post partum hemorrhage. 4-increase risk of operative birth 4-increase risk of operative birth

@fetus : 1- bone injury. 1- bone injury. 2-soft tissue trauma. 2-soft tissue trauma. 3-hypoxia. 3-hypoxia. 4-cerebral hemorrhage. 4-cerebral hemorrhage. 5-still birth. 5-still birth.

@neonate : 1- SGA ( small gestational age ) 1- SGA ( small gestational age ) 2- me conium aspiration. 2- me conium aspiration. 3-asphyxia. 3-asphyxia.

Goal : reach optimum outcome for mother & baby. Predisposing factors of prolonged pregnancy : Predisposing factors of prolonged pregnancy :

@previous prolonged prolonged null null mass index of pregnancy more than mass index of pregnancy more

management of prolonged pregnancy consent form need to take by mother & her husband to do induction of labor. consent form need to take by mother & her husband to do induction of labor. To assess fetal being do : To assess fetal being do : NST :non stress test & u\s to estimate AFV by using amniotic fluid index AFI NST :non stress test & u\s to estimate AFV by using amniotic fluid index AFI

CTG. CTG. -Monitor FHR with two acceleration of more than 15 seconds,above base line in 20 minutes. -Monitor FHR with two acceleration of more than 15 seconds,above base line in 20 minutes. Any irregularities mean non reassuring CTG. Any irregularities mean non reassuring CTG.

* membrane sweep : * membrane sweep : -Done at 41 weeks gestation, Increase onset of spontaneous labor physiologically, to avoid use of prostaglandin,AROM,& oxytocin. -Done at 41 weeks gestation, Increase onset of spontaneous labor physiologically, to avoid use of prostaglandin,AROM,& oxytocin.

* procedure : * procedure : - introducing the examining fingers into cervical os & passing them in circular way around the cervix this lead to increase secretion of prostaglandin at local area this procedure done also if cervix closed. - introducing the examining fingers into cervical os & passing them in circular way around the cervix this lead to increase secretion of prostaglandin at local area this procedure done also if cervix closed. Procedure can be repeated Procedure can be repeated

induction of labor : IOL *Done at 41 weeks gestation. *Done at 41 weeks gestation. Used to uncomplicated pregnancy. Used to uncomplicated pregnancy. Could be done at 42weeks gestation. Could be done at 42weeks gestation. Full assessment should be done. Full assessment should be done.

* indications of IOL : * indications of IOL : 1- PIH. 1- PIH. 2- GDM. 2- GDM. 3-IUGR. 3-IUGR. 4-macrosomia. 4-macrosomia. 5-social reason 5-social reason

@ maternal indications maternal indications : * prolonged pregnancy. * prolonged pregnancy. *HTN,PIH,according to mother symptoms. *HTN,PIH,according to mother symptoms. *DM,still birth,macrosomia. *DM,still birth,macrosomia. *prelabor ROM after 24hours of ROM. *prelabor ROM after 24hours of ROM. *maternal request,psychological & social reason *maternal request,psychological & social reason

indications indications : *IUGR less than 34weeks. *IUGR less than 34weeks. *macrosomia,decrease incidence of shoulder dystocia. *macrosomia,decrease incidence of shoulder dystocia. *fetal death. *fetal death. *fetal anomaly. *fetal anomaly.

@ contraindication of IOL contraindication of IOL ; * placenta previa. * placenta previa. *transverse lie ( compound presentation. *transverse lie ( compound presentation. *HIV positive woman. *HIV positive woman. * active genital herpes. * active genital herpes. *cord presentation & cord prolapse. *cord presentation & cord prolapse. *known case of CPD *known case of CPD *severe acute fetal compromise. *severe acute fetal compromise.

@ method of induction method of induction : -favorable cervix ( dilated & effaced). -favorable cervix ( dilated & effaced). -descent of the presenting part. -descent of the presenting part. -before induction,abdominal examination should be done. -before induction,abdominal examination should be done. -use of bishop score. -use of bishop score. -transvaginal u\s to assess length of the cervix. -transvaginal u\s to assess length of the cervix.

@ membrane sweep membrane sweep : -done after 40weeks. -done after 40weeks. -carried out by Dr or midwife. -carried out by Dr or midwife. -safe procedure. -safe procedure. -it recommended to do before IOL. -it recommended to do before IOL. Side effect : - doesn ’ t reduce the need of IOL. Side effect : - doesn ’ t reduce the need of IOL. - cause discomfort. - cause discomfort. - irregular contraction. - irregular contraction.

@ prostaglandin E2( pGE2) dinoprostone prostaglandin E2( pGE2) dinoprostone : -PGE2& PGF2 normally produced by cervix,uterus,deciduas,&fetal membrane. -PGE2& PGF2 normally produced by cervix,uterus,deciduas,&fetal membrane. -act locally on these structure. -act locally on these structure. -PGE2 vaginal tab.,gel,pessaries. -PGE2 vaginal tab.,gel,pessaries. -

placed in the posterior fornix of the vagina. placed in the posterior fornix of the vagina. -it absorbed by epithelium of the vagina & cervix. -it absorbed by epithelium of the vagina & cervix. Action : -relaxation & dilatation of the cervix. Action : -relaxation & dilatation of the cervix. -uterine muscle contraction. -uterine muscle contraction. It potentiate the effect of oxytocic agent. It potentiate the effect of oxytocic agent.

* following insertion of prostaglandin : * following insertion of prostaglandin : 1- woman lies down for 30 minutes. 1- woman lies down for 30 minutes. 2-attach with CTG. 2-attach with CTG. 3-recommended dose PGE23mg tab. 3-recommended dose PGE23mg tab. 4- assess after 6hrs. 4- assess after 6hrs. 5- if no response another 3mg inserted in the posterior fornix of the vagina. 5- if no response another 3mg inserted in the posterior fornix of the vagina. 6-maximum dose 6mg. 6-maximum dose 6mg. PGE2gel 4mg. PGE2gel 4mg.

* disadvantages : * disadvantages : Nausea. Nausea. Vomiting. Vomiting. Diarrhea. Diarrhea. N.B :use of oxytocic agent after 6hrs of prostaglandin. N.B :use of oxytocic agent after 6hrs of prostaglandin.

* PGE1 (misoprostol): * PGE1 (misoprostol): - oral. - oral. -sublingual. -sublingual. -vaginal. -vaginal. -200mcg IOL. -200mcg IOL. -more effective. -more effective. -less expensive. -less expensive. -if used with oxytocic agent cause hyper stimulation. -if used with oxytocic agent cause hyper stimulation.

-* risk of prostaglandinE2: -* risk of prostaglandinE2: - hypertonic uterus. - hypertonic uterus. -abruptioplacenta. -abruptioplacenta. -fetal hypoxia. -fetal hypoxia. -pulmonary,amniotic fluid embolism. -pulmonary,amniotic fluid embolism. -rare uterine rupture. -rare uterine rupture. - c.s delivery. - c.s delivery.

@ AROM AROM : -amniotomy. -amniotomy. -used to induce labor if cervix is favorable & fixed presenting part. -used to induce labor if cervix is favorable & fixed presenting part. -do abdominal examination before. -do abdominal examination before. -vaginal examination. -vaginal examination. -bag of water lying in front of the presenting part ( fore water) ruptured by amniohook. -bag of water lying in front of the presenting part ( fore water) ruptured by amniohook. -asses fluid for color,volume. -asses fluid for color,volume. -

check FHR. check FHR. -increase risk of chorioamniotis. -increase risk of chorioamniotis. -ascending infection of genital tract,increase perinatal mortality rate. -ascending infection of genital tract,increase perinatal mortality rate. -establish of oxytocin after ROM. -establish of oxytocin after ROM. -PGE2produced from amnion & cervix,during pregnancy chorine secret enzyme called PGDH(prostaglandins dehydregnase enzyme ) that break PGE2thus preterm labor is avoided. -PGE2produced from amnion & cervix,during pregnancy chorine secret enzyme called PGDH(prostaglandins dehydregnase enzyme ) that break PGE2thus preterm labor is avoided.

@ oxytocin : -act on smooth muscle,secreted from posterior pituitary oxytocin : -act on smooth muscle,secreted from posterior pituitary gland. receptors of oxytocin found on myometrium.. receptors of oxytocin found on myometrium.. - syntocinon is synthetic of oxytocin uterotonic agent. - syntocinon is synthetic of oxytocin uterotonic agent. -used for IOL after AROM done. -used for IOL after AROM done.

I.V drip slowly. I.V drip slowly. Put in normal saline. Put in normal saline. Monitor FHR,& uterine condition. Monitor FHR,& uterine condition. - observe for hypertonic uterine contraction. - observe for hypertonic uterine contraction. - monitor intensity,duration,frequency of uterine contraction. - monitor intensity,duration,frequency of uterine contraction.

.*risk of oxytocin:.*risk of oxytocin: -hypertonic (hyper stimulation ) -hypertonic (hyper stimulation ) - fetal hypoxia. - fetal hypoxia. -uterine rupture. -uterine rupture. -fluid retention. -fluid retention. -post partum hemorrhage. -post partum hemorrhage. -amniotic fluid embolism (AFE) -amniotic fluid embolism (AFE)

********* midwifery role toward induction of labor : ********* midwifery role toward induction of labor : -proper antenatal care. -proper antenatal care. -intrapartum care. -intrapartum care. -full explanation about induction. -full explanation about induction. -fill part gram. -fill part gram

monitor side effect of each type. monitor side effect of each type. -abdominal examination & vaginal examination. -abdominal examination & vaginal examination. - u\s. - u\s. -give pain relieve -give pain relieve

* alternative approach to initiate labor : * alternative approach to initiate labor : 1-ingestion of caster oil. 1-ingestion of caster oil. 2-nipple stimulation. 2-nipple stimulation. 3-sexual intercourse. 3-sexual intercourse. 4-acupuncture. 4-acupuncture. 5-homeopathic method. 5-homeopathic method.