Post Term 08

PRAYER TO ST.
THOMAS AQUINAS
PATRON OF STUDENTS
• Wonderful Theologian and Doctor of the
Church, you learned more from the Crucifix
than from books. Combining both sources, you
left us the marvelous Summa of theology,
broadcasting more glorious enlightenment to
all. You always sought for the true light and
studied for God’s honor and glory. Help us to
study without ambition and pride in imitation of
you. Amen.
POSTTERM PREGNANCY,
FETAL GROWTH RESTRICTION,
FETAL DEATH,
UMBILICAL CORD PROLAPSE
Shirley H. Virata, M.D., FPOGS

Dept. of Obstetrics & Gynecology
Postterm Pregnancy
Postterm Pregnancy
• Postterm
• Prolonged
• Postdate
• Postmature
Postterm Pregnancy
• Definition (ACOG) – 42 completed

weeks (294 days) or more from the
1st day of the LNMP.
Postterm Pregnancy
• The categories of pregnancies that

reach 42 completed weeks
1. Those truly 40 wks past conception
2. Those of less advanced gestation due
to inaccurate estimation of gestational
age
a. Faulty recall of date of LNMP
b. Variations in menstrual cycle
Postterm Pregnancy
• Incidence:
– 7% of 4,000,000 infants born on the US
were delivered 42 weeks or more
– 10-27% if 1st born was postterm
– 39% if 2 previous postterm deliveries
Postterm Pregnancy
• Perinatal Mortality
– Increased after the expected date due
date was passed
• Major causes of death
1. pregnancy hypertension
2. prolonged labor with CPD
3. unexplained “anoxia”
4. malformations
Postterm Pregnancy
• Pathophysiology:
Postmature infants
Die seriously ill

(birth asphyxia
meconium aspiration)
brain damage
Postterm Pregnancy
• Features of Postmaturity Syndrome
– Skin: wrinkled, patchy, peeling
• Wrinkling prominent in palms and soles
– Long nails
– Body: long thin
– Open eyed, unusually alert
– Appears old and worried looking
Postterm Pregnancy
• Placental dysfunction
– Placental apoptosis increased 
decreased fetal oxygenation in some
postterm gestation
– Postterm fetuses may continue to gain

weight and be unusually large at birth
Postterm Pregnancy
• Fetal distress and oligohydramnios -

decreased amniotic fluid 
– antepartum fetal jeopardy and
intrapartum fetal distress due to cord
compression
– Meconium release  meconium
aspiration syndrome
Postterm Pregnancy
• Fetal growth restriction

– 1/3 of postterm stillbirth were growth
restricted
– Mortality and morbidity were
significantly increased in growth
restricted infants
Postterm Pregnancy
• Management:
– Unfavorable cervix (Bishop score of 4 or
less)
– ACOG (1997) prostaglandin gel can be
safely used in postterm pregnancy for
cervical ripening
Bishop Scoring System Used for
Assessment of Inducibility
Factor
Score Dilatation Efface Station Cervical Cervical
(cm) ment (-3 to Consisten position
(%) +3) cy
0 closed 0-30 -3 firm posterior
1 1-2 40-50 -2 medium mid

position
2 3-4 60-70 -1 Soft anterior
3 >5 >80 +1, +2 -- -

Postterm Pregnancy
• Induction of Labor
– Stripping of membranes at 38-40 wks decreased
the frequency of postterm pregnancy
– Oxytocin drip
• 1000 ml D5RL + 10 units oxytocin  10 mu/ml
• Starting dose 0.5 – 1 mu/min.
• Incremental dose 1 mu/min every 15 mins.
• Uterine response within 3-5 mins. of beginning an
oxytocin infusion
• Discontinue if uterine contractions more than 5/10 mins.
or 7/15 mins with a persistent non-reassuring FHR
pattern
• Half-life approximately 5 mins.
Postterm Pregnancy
• CS rate was directly related to

station
– If vertex is – 1 - 6%
-2 - 20%
-3 - 43%
-4 - 77%
Evaluation & Management of
Postterm Pregnancy
• Postterm pregnancy is defined as a
pregnancy that has extended to or
beyond 42 completed weeks
• Women with a postterm gestation
who have an unfavorable cervix can
either undergo labor induction or be
managed expectantly.
• Prostaglandin can be used for
cervical ripening and labor induction.
Postterm Pregnancy
• Delivery should be effected if there is
evidence of fetal compromise or
oligohydramnios.
• It is reasonable to initiate antenatal
surveillance between 41 and 42
weeks despite lack of evidence that
monitoring improves outcomes.
Postterm Pregnancy
• A nonstress test and amniotic fluid
volume assessment should be
adequate, although no single method
has been shown to be superior.
• Many recommend prompt delivery in
a woman with a postterm pregnancy,
a favorable cervix, and no other
complications.
Postterm Pregnancy
• Management at Parkland Hospital
– AOG is certain at 42 weeks
• Induce labor – 90% successful induction or
enter labor within 2 days of induction
undelivered
2nd induction within 3 days  almost all are
delivered
3rd induction
Postterm Pregnancy
• Management at Parkland Hospital

– AOG is uncertain at 42 weeks
• Weekly follow-up unless fetal jeopardy is
suspected based (1) on clinical or
sonographic perception of decreased
amniotic fluid volume (2) decreased fetal
movement
• If fetal jeopardy-induce labor
Postterm Pregnancy
• Do not allow pregnancy to go

beyond 42 weeks in cases of
pregnancy induced hypertension,
previous cesarean section &
diabetes mellitus.
Postterm Pregnancy
• Intrapartum Management
– Labor is a dangerous time for the postterm
infant
– Admit as soon as in labor
– Electronic fetal monitoring of uterine
contractions and FHR
– Amniotomy??
• Can increase possibility of cord compression
in oligohydramnios
• Aids in diagnosis of thick meconium
– Amnioinfusion X
Postterm Pregnancy
• Likelihood of successful vaginal
delivery is decreased in nulliparous
women in early labor with meconium
stained amniotic fluid. Therefore, if
remote from delivery, consider CS if
CPD is suspected or either hypotonic
or hypertonic dysfunctional labor is
present.
Postterm Pregnancy
• Minimize aspiration of meconium by

suctioning pharynx as soon as head
is delivered but before thorax is
delivered.
• If meconium found in pharynx
aspirate trachea and ventilate infant
if needed.
Fetal Growth
Restriction
Fetal Growth Restriction
• Low birth weight of less than 2500

gms at term
• Incidence: 8%
• Fetal growth curve (Lubchenco)
3 Phases of Cell Growth
1st phase 2nd phase 3rd phase
Occurrence During the 1st Extends to 32 After 32 wks.
16 wks. wks.
Change Rapid Cellular Fetal growth
increase in hyperplasia & by cellular
cell number hypertrophy hypertrophy
(cellular Fetal fat &
hyperplasia) glycogen
deposition
Fetal growth 5 gms/day at 15-20 30-35
rate 15 wks. gms/day at gms/day
24 wks.
• Factors in fetal growth rate

1. Insulin and insulin-like growth factor
2. Obesity gene and its’ protein product
leptin
3. Adequate supply of nutrients
• Perinatal morbidity and mortality
1. Fetal demise
2. Birth asphyxia
3. Meconium aspiration
4. Neonatal hypoglycemia
5. Neonatal hypothermia
6. Abnormal neurological development
• Postnatal growth and development

depends on:
1. Cause of restriction
2. Nutrition in infancy
3. Social environment
• Symmetrical vs. asymmetrical
growth restriction
– Use ultrasound to determine head
circumference and abdominal
circumference
– Symmetrical growth restriction –
proportionately small
– Asymmetrical growth restriction –
disproportionately lagging abdominal
growth
• Onset of etiology of an insult relates to the
type of growth restriction
• Early insult  relative decrease in cell
number and size  proportionate reduction
of head and body size  symmetrical growth
restriction
• Hypertension  placental insufficiency  ↓
glucose transfer and hepatic storage 
decreased liver size  decreased abdominal
circumference
• Risk factors:
1. Constitutionally small mother
2. Poor maternal nutrition
3. Social deprivation
4. Fetal infection
5. Congenital malformation
6. Chromosomal aneuploidies
7. Disorders of cartilage and bone
8. Teratogens
• Risk factors:
1. Vascular disease
2. Renal disease
3. Chronic hypoxia
4. Anemia
5. Placental and cord abnormalities
6. Multiple fetuses
7. APAS
8. Extrauterine pregnancy
• Identification of fetal growth
restriction
1. Early establishment of gestational age
2. Attention to maternal weight gain
3. Careful measurement of uterine fundal
growth
4. Ultrasonic measurements
5. Doppler velocimetry
• Management
– Goals
• Confirm diagnosis
• Assess fetal condition
• Evaluate for anomalies
• Determine timing of delivery
• Near term
– Prompt delivery is best -
– 34 wks. or beyond – deliver if there is
clinically significant oligohydramnios
– Reassuring FHR pattern – may deliver
vaginally
• Remote from term (prior to 34 wks.)
– AFV (Normal) } observe
– Fetal surveillance (Normal) }
– Fetal growth continuous }continue until
– Fetal evaluation (Normal) } fetal maturity
– Evaluate every 4-6 weeks to predict FGR
• Remote from term (prior to 34 wks.)
– No specific treatment ameliorates the
condition
• Bed rest }
• Nutrient supplementation } ineffective
• Plasma volume expansion }
• Oxygen therapy }
• Anti hypertensive drug }
• Heparin }
• Aspirin }
• Management decision is dependent
on assessment of the relative risk of
death with expectant management
vs. the risk from preterm delivery
• Mortality & morbidity is determined
primarily by gestational age and birth
weight
• Labor and delivery
– CS is increased due to:
• Placental insufficiency
• Decreased AFV  cord compression
• Infant morbidity: Causes
1. Hypoxia and meconium aspiration
2. Hypothermia
3. Hypoglycemia, polycythemia &
hyperviscosity
4. Motor and neurological disability
Antepartum Fetal
Death
Antepartum Fetal Death
• Etiology:
1. Idiopathic – in half of cases
2. Maternal complication
a. Preeclampsia
b. Placenta previa
c. Abruptio placenta
d. Diabetes
3. Fetal disease
a. Congenital anomalies
b. Erythroblastosis
c. Chorioamnionitis following PROM
• Diagnosis:
– Symptoms:
• Cessation of fetal movement
• Disappearance of gestational symptoms
• Cessation of growth
• Decreased in size and tenderness of breast
– Signs:
• No fetal heart tone
• No palpable fetal movement
• Size of uterus smaller than expected AOG
• Diagnosis:
– Ultrasonic technique
• Absence of cardiac activity and fetal
movement
• Loss of clarity of the outline of the body
• Increase in no. of echoes coming from the
fetal body
• Collapse of fetal skull
• Failure of fetal growth
• Diagnosis:
– X-ray of the abdomen
• Loss of fetal tone – exaggeration of fetal
spine curvature
• Spalding sign – overlapping of cranial bone
• Robert’s sign - gas bubbles in the fetus
– Negative pregnancy test
– Maternal excretion of estriol falls to
undetectable levels in 24-48 hours
Categories & Causes of Fetal Death
A. Fetal (25-40%)
1. Chromosomal anomalies
2. Nonchromosomal birth defects
3. Nonimmune hydrops
4. Infections – viruses, bacteria, protozoa
A. Placental (25-35%)
1. Abruption
2. Fetal-maternal hemorrhage
3. Cord accident
4. Placental insufficiency
5. Intrapartum asphyxia
6. Previa
7. Twin-to-twin transfusion
8. Chorioamnionitis
A. Maternal (5-10%)
1. Antiphospholipid antibodies
2. Diabetes
3. Hypertensive disorders
4. Trauma
5. Abnormal labor
6. Sepsis
7. Acidosis
8. Hypoxia
9. Uterine rupture
10. Postterm pregnancy
11. Drugs
B. Unexplained (25-35%)
• Management:
– Expectant
• Spontaneous labor and delivery will take place
within 2 weeks of fetal death in 75% of cases
and by 3 weeks in 90% of cases
– Active management
• First trimester
– Dilatation of the cervix and aspiration curettage
• Second and third trimester
– Ripe cervix – oxytocin drip
– Unripe cervix – prostaglandin
• Complication
– DIC
• It is unlikely that hypofibrogenemia
will develop before 4-6 weeks of fetal
death has occurred
• Weekly measurements of levels of
fibrinogen
• Management: cryoprecipitate; whole
blood
Intrapartum Fetal Death
• Definition:
– Documentation of fetal heart tones after
the onset of labor
– No sign of life after delivery of the child
• Etiology:
A. Definite causes of death:
1. Difficult and traumatic delivery
2. Prolapse of the cord
3. Abruptio placenta
4. Congenital anomalies incompatible with
life
5. RH sensitization
6. Ruptured uterus
A. Etiology:
1. Concomitant problems
• Highly significant conditions
a. Prolonged gestation
b. PROM
c. Tight cord around the neck
d. Paracervical block anesthesia
• Etiology:
A. Concomitant problems
1. Mildly significant conditions
a. Intrapartum fever
b. Preeclampsia
c. Maternal hypotension
d. Breech
e. Abnormal sugar tolerance
Fetal Death
• Evaluation of the stillborn infants
– Determining the cause of fetal death
1. Facilitates the psychological adaptation to a
significant loss
2. Helps to assuage the guilt that is part of
grieving
3. Makes counseling regarding recurrence more
accurate
4. May prompt therapy or intervention to
prevent a similar outcome in the next
pregnancy
5. Identification of inherited syndromes
Fetal Death
• Evaluation of the stillborn infants
– Clinical examination
1. Thorough examination of the fetus,
placenta and membrane
2. Details of relevant prenatal events
3. Take photographs; perform a full
radiograph of the fetus (fetogram)
Protocol for Examination of
Stillborn Infants
A. Infant Description
– Malformations
– Skin staining
– Degree of maceration
– Color – pale, plethoric
B. Umbilical cord
– Prolapse
– Entanglement – neck, arms, legs
– Hematomas or strictures
– Number of vessels
– Length
– Wharton jelly – normal, absent
Stillborn Infants
A. Amniotic fluid
– Color – meconium, blood
– Consistency
– Volume
B. Placenta
– Weight
– Staining – meconium
– Adherent clots
– Structural abnormalities – circumvallate or
accessory lobes, velamentous insertion
– Edema – hydropic changes
Stillborn Infants
A. Membranes
– Meconium stained or cloudy
– Thickening
Fetal Death
• Psychological aspects
– Psychological trauma and stress
results from:
1. More than 24 hours between diagnosis of
fetal death and induction of labor
2. Not seeing the infant as long as she desire
3. Having no tokens of remembrance
– Increased risk of postpartum
depression
Fetal Death
• Pregnancy after previous stillbirth
– Conditions associated with increase
recurrent stillbirth:
1. Hereditary disorders
2. Maternal conditions
a. Diabetes
b. Chronic hypertension
Fetal Death
• Pregnancy after previous stillbirth
– Prenatal evaluation
1. Chorionic villous sampling or
amniocentesis for aneuploidy
2. Stringent blood pressure control to
prevent hypertension and/or abruptio
3. Diabetic screening; intensive glycemic
control in preconceptional period
4. Test for APAS
Umbilical Cord
Prolapse
Umbilical Cord Prolapse
• Definition: presentation of the
umbilical cord below or adjacent to
the fetal presenting part.
• Types:
1. Overt umbilical cord prolapse
2. Occult umbilical cord prolapse
3. Funic umbilical cord prolapse
• Incidence: 0.17% to 0.4% of births
• Risk Factors:
1. Malpresentation
2. Hydramnios
3. Prematurity
4. Grandmultiparity
5. Pelvic tumors
6. Placenta previa and low lying placenta
7. CPD
8. Multiple gestation
9. PROM
• Associated obstetrical intervention
1. Amniotomy
2. Attempted external cephalic version
3. Manual rotation of the fetal head
4. Expectant management of PPROM
5. Scalp electrode application
6. Intrauterine pressure catheter
insertion
7. Amnioreduction
• Prevention:
– Education of women with risk factors for cord
prolapse
• Be aware of the potential for cord prolapse
• The need to call for help urgently
• Positions that would be helpful
• Intervention that would occur in the event of cord
prolapse
– Fetal surveillance at time of membrane
rupture
– Time amniotomy properly & the presenting
part should be properly applied to the cervix
• Mortality & Morbidity

– Low apgar scores and low cord pH 
significant morbidity
– Mortality (perinatal) – 0.02% to 12.6%
• Diagnosis of overt cord prolapse
– Visualizing the cord thru the introitus
– Palpation of the cord in the vagina
• Sudden FHR deceleration in rupture

of membrane is often the first
indication of cord prolapse. Vaginal
examination is necessary for non-
reassuring fetal surveillance.
• Diagnosis of occult cord prolapse
– Suspect when decelerations are present
either by auscultation or electronic fetal
monitoring.
– Fetal heart monitoring will show
variable decelerations during
contraction with prompt return to
baseline.
• Diagnosis of funic cord prolapse

– Palpation of the cord through the
membranes or as an incidental finding
on ultrasound
• Management of overt cord prolapse

– Emergency situation
• Call for help
• Pelvic exam to determine cervical dilatation
and effacement, station of the presenting
part and the strength and frequency of
pulsation within the cord vessel.
– Cord pulsations present
• Leave examining hand in place to elevate or
push up the presenting part
• Knee chest or Trendelenberg position
• Do not attempt to explore the cord. Keep it
warm and avoid manipulation of the cord.
• Give oxygen
• Prepare for CS or transfer to hospital
• Prepare for resuscitation of a potentially
depressed infant.

• If transfer unavailable, allow the labor to
progress and talk to the woman about the
probable death of the baby
• Imminent delivery
– Prepare for vaginal delivery while preparing for a
CS
» Call for additional help
» Prepare for neonatal resuscitation
» Woman in upright position or squat position
to help in progress of labor
» Expedite delivery by encouraging the woman
to push with each contraction
» Fully dilated cervix with engaged head –
assist vaginal delivery with vacuum or
forceps

• If prolonged time to cesarean section or
transport to another center
– Fill the bladder with 500 – 700 cc NSS
– Tocolysis
– Cord pulsations absent
• Explain to the woman that the baby has died
• Confirm absence of fetal heart tone
• Discuss options for management
– Wait for labor to begin or progress
– Induction or augmentation as needed
– Provide emotional and other support as needed
– Transfer to a higher level facility if indicated
• Management of funic cord prolapse
– Elective CS prior to rupture of
membrane
– If diagnosed in the 3rd trimester repeat
ultrasound
– For viable premature infants - bed rest
in Trendelenberg position until the cord
moves or the woman is safe to deliver

Post Term 08

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PRAYER TO ST.

Shirley H. Virata, M.D., FPOGS

• Definition (ACOG) – 42 completed

• The categories of pregnancies that

Die seriously ill

– Postterm fetuses may continue to gain

• Fetal distress and oligohydramnios -

• Fetal growth restriction

1 1-2 40-50 -2 medium mid

3 >5 >80 +1, +2 -- -

• CS rate was directly related to

• Management at Parkland Hospital

• Do not allow pregnancy to go

• Minimize aspiration of meconium by

• Low birth weight of less than 2500

• Factors in fetal growth rate

• Postnatal growth and development

• Mortality & Morbidity

• Sudden FHR deceleration in rupture

• Diagnosis of funic cord prolapse

• Management of overt cord prolapse

• Management of overt cord prolapse

• Management of overt cord prolapse

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