This document discusses post-term pregnancy, which refers to pregnancies that go beyond 42 weeks gestation. It defines key terms like early, full, late, and post-term. Post-maturity syndrome affects 10-20% of pregnancies at 42 weeks and is characterized by wrinkled skin and wasting. Risk factors for post-term pregnancy include inaccurate dating, genetic factors, and previous post-term pregnancies. Complications include fetal distress, meconium aspiration, and increased need for induction and C-section. Management of post-term pregnancy involves induction of labor at or beyond 42 weeks or expectant management with fetal surveillance.

1. Supervisor:
Prof: Enas Hamdy
Dr: Rahma Saed

2. 
*Introduction
*Definitions
*Post maturity syndrome
*Epidemiology
*Pathophysiology
*Diagnosis
*Investigations
*Complications
*Management
*CTG interpretation
contents

3. 
Post term pregnancy is a common situation .
It causes anxiety for both women and obstetricians
as being as a cause of maternal , fetal and neonatal
risks.
Post term pregnancy per se is not a pathological
condition and should not be confused with the post
.
maturity syndrome (described in1954)
Introduction

4. 
DEFINITIONS

5. 
Neonate born any time after 37 completed weeks of
gestation and up until 42 completed weeks .
*Early term?
*Full term?
*Late term?
*Post term?
Term pregnancy

6. 
*Early term: refer to neonate born at 37w completed up
to 38 w.
*Full term: refer to neonate born at 39 w completed up
to 40 w.
*Late term: refer to neonate born at 41 w completed up
to 42 w.
*Post term: refer to progress beyond 42
w.

7. 
*International definition of Post term , post date and
prolonged pregnancy is pregnancy exceed beyond
42+0/7 weeks namely (294 days ) or more from the 1st
day of the last menstrual period.
*Prolonged pregnancy is associated with fetal ,
maternal and neonatal complication.

8. 
*Definition
*Incidence
*Features
*stages
Post maturity syndrome

9. 
*Definition:
It is uncommon specific clinical fetal syndrome in which the
newborn has recognizable features indicating a pathological
prolonged pregnancy.
*Incidence:
The syndrome complicates 10 to 20 % of pregnancy at 42
completed weeks .
associated oligohydramnios substantially raises the
likelihood of postmaturity. defined by a sonographic
maximal vertical amniotic fluid pocket that measured ≤1 cm
at 42 weeks.
Post maturity
syndrome

10. 
*Skin:
wrinkled, patchy , peeling skin particularly
prominent on the palm and soles .
*Long, thin body suggesting wasting .
*Open eyed, alert and appear old.
*The nails are typically long.
Features of post mature
newborn

11. 
*Most postmature neonates are not technically growth
restricted because their birth weight seldom falls below
the 10th percentile.
*However, severe growth restriction which logically
must have preceded completion of 42 weeks may be
present.

12. 
Stage I: dry skin ( loss of subcutaneous fat).
Stage II: meconium staining of amniotic fluid.
Stage III: bright yellow staining of nail , skin , umbilical
cord, membranes and placenta.
Criteria for post maturity
classified as

13. 

14. 

15. 
The use of ultrasound in early pregnancy for precise dating
is thought to reduce the number of post term pregnancies
compared to dating based on the LMP.
*6.9% based on LMP.
*2% based on first trimester US.
*overall 5-10% of pregnancies are prolonged beyond 42
weeks.
*around 20% of pregnant women will need induction of
labour (the majority for post term pregnancy).
Epidemiology

16. 
1- miscalculating the date (Commonest cause).
2-x-linked sulfatase deficiency in the placenta.
3-Central nervous system abnormalities.
4-Adrenal gland hypoplasia.
5- previous post term pregnancy increases the risk of
recurrence in subsequent pregnancy.
6-primigravida.
7-high maternal BMI : elevated pre-pregnancy weight
and maternal weight gain both increase the risk of post
term delivery.
Risk factors

17. 
8- genetic factors:
there is increased risk of post term pregnancy for
mothers who where themselves born post term and
twin studies also suggest a genetic role.
9- advanced maternal age .
10- tocolytic medication use:
Antiprostaglandins (as in rhumatoid ,SLE) or beta-
mimetics (as in asthma).

18. 
1- Placental dysfunction:
Fetal growth continues until at least 42 weeks. But
umbilical blood flow does not increase concomitantly.
2- fetal distress and oligohydramnios:
Due to oligohydramnios and viscous meconium that
may cause meconium aspiration syndrome .
3- Macrosomia: weight 4000 g is 8% at 37 weeks to 41
weeks.
Weight 4000 g is 11% at 42 weeks or more.
4- Post maturity syndrome.
Pathophysiology

19. 
25-50% of cases diagnosed as post term are not true post term due
to:
Inaccurate menstrual data due to poor memory.
Irregular cycle.
Lactational amenorrhea.
Contarceptive pills taken before pregnancy( may cause delayed
ovulation).
Diagnosis

20. 
*Confirmation of the gestational age :
*History →EDD:
1. The patient is sure of her dates
2. At least previous 3 regular cycles
3. No COC for the last 3 months < pregnancy
*Clinical → Fundal level corresponding to period of amenorrhea
(DD for ↑ or ↓) and fetal weight.

21. 
*History of one of predisposing factors .
*Patient exceeded her EDD ( GA must be accurate )
Fetal kicks weaker
*Patient feels:
.(
or( more painful dt oligohydramnios
history

22. 
* maternal weight .
*Signs of oligohydramnios .
*Large fetal size or small ( dt IUGR & oligohydramnios ) +
hard fetal head.
*Local examination for Bishop score .
examination

23. 

24. 
1. To diagnose post term( confirmation of GA):
i. Date of 1st day of LMP to calculate EDD by naegele's rule.
ii. US: BPD > 9.5 cm , placenta grade 3 , marked
.
turbidity of AF , oligohydraminos
*CRL: ±3-5 days
*ultrasound at 12-20 w:±1 week
*at 20-30 weeks:±2 w
*after 30 weeks: ±3 w.
iii. Date of pregnancy test.
iv. Date of quickening.
v. Fundal level.
investigations

25. 
2. To diagnose fetal wellbeing: US , BPP ,CTG

26. 
Complications

27. 
*prolonged labour
*Obstructed labour
*Perineal damage
*Instrumental vaginal delivery
*Need for cesarean section
*post partum hemorrhage
*infection
*Traumatic delivery
maternal complications

28. 
Perinatal mortality:
There is increased risk of stillbirth , neonatal death and
risk of death in the first year of life.
The increased mortality is thought to be due to factors
such as utero placental insufficiency, meconium
aspiration and intrauterine infection .
Fetal & neonatal

29. 
Fetal morbidity:
1-post mature syndrome.
2-meconium aspiration .
3-macrosomia resulting in:
*prolonged labour
*cephalo-pelvic disproportion
*shoulder dystocia
*birth injury for example brachial plexus injury or
cerebral palsy.

30. 
4-neonatal acidaemia.
5-low five-minute apgar scores.
6-neonatal encephalopathy.
7-neonatal seizures.
8-features of IUGR due to placental insufficiency.

31. 

32. 
1- induction of labour.
2- conservative management.
3- Cesarean section.
*there is controversry on whether to conserve till 41
or 42 w or to terminate once term is reached.
Management

33. 
*After completing 42 weeks, labor induction is
recommended to help avoid the just-described
morbidity and mortality.
*For late-term gestations , decision focuses on whether
labor induction or if expectant management with fetal
surveillance is best.
*Most of the performed is twice-weekly fetal
antepartum testing until 42 completed weeks.
Induction

34. 
At this time, evidence is insufficient to mandate
a management strategy between 40 and 42 completed
weeks.
Thus, induction of labor or initiation of fetal surveillance at
41 weeks gestation is a reasonable option.
The American College of Obstetricians and Gynecologists and
the Society for Maternal-Fetal Medicine (2021) suggest that
fetal surveillance should be done once or twice weekly
beginning at 41 0/7 weeks. After completing 42 weeks, labor
induction is recommended.

35. 
*cervical favourability:
1- If the cervix is favourable:
Oxytocin iv infusion + early AROM.
2- If the cervix is unfavourable:
Ripining of the cervix , oxytocin iv infusion + early AROM.
■ Induction Factors

36. 
Induction without cervical dilation had a two
fold
higher cesarean delivery rate.
Instead, If cervical length ≤25 mm with transvaginal
sonography positively predicted spontaneous labor or
successful induction.

37. 
*Several investigators have evaluated prostaglandin E2
(PGE2) and E1 (PGE1) for induction in women with an
.
unfavorable cervix
*Induction of labour is more likely to succeed when the
cervix is favourable.
*A favourable cervix is defined as a cervix with Bishop score
of ≥ 6 in post term pregnancy.

38. 
*Sweeping or stripping of the membranes
to induce labor and thereby prevent post term
pregnancy has been evaluated.
It is found that membrane stripping slightly increased
spontaneous labor and lowered induction rates.
(However, this practice did not lower the cesarean
delivery rate).
Other trials have found that sweeping membranes did
not reduce the need to induce labor (Drawbacks of
membrane stripping included pain, vaginal bleeding,
and irregular contractions without labor.

39. 
■ Induction versus Fetal
Testing
*To further address the question, the SWEdish Post-term
Induction Study —SWEPIS—was a randomized trial
that included 2760 low-risk pregnancies at 41 weeks’
gestation.
* The trial compared outcomes with induction of labor
at 41 weeks against expectant management and
induction at 42 weeks. As shown in Table, maternal and
perinatal outcomes were not different.

40. 
*Prolonged fetal heart rate deceleration before
emergency cesarean delivery in a
Post term pregnancy with oligohydramnios.

41. 
Selected Maternal and Perinatal
Outcomes from SWEPIS Trial

42. 
Algorithm for management of post term pregnancy

43. 
INTRAPARTUM
MANAGEMENT
*Labor is a particularly dangerous time for the post
term fetus.
Labour should be closed monitoring by :
1- fetal heart rate and uterine contractions are
monitored electronically for variations consistent with
fetal compromise.

44. 
2- the decision to perform amniotomy is problematic.
Further reduction in fluid volume following
amniotomy can enhance the possibility of cord
compression. Conversely, after membrane rupture,
a scalp electrode and an intrauterine pressure catheter
can be placed. These usually provide more precise data
concerning fetal heart rate and uterine contractions
.

45. 
3-assessment the colour of the
liquor.
.
Amniotomy also aids identification of thick meconium
4-cs indicated for:
* fetal distress .
*Fetal macrosomia >4kg .
*failed induction .
*other obstetric indication.

46. 
When reviewing a CTG trace, assess and document:
• contractions
• baseline fetal heart rate
• variability
• presence or absence of decelerations (and
characteristics of decelerations if
present)
• presence of accelerations.
.
Catagorized as white, amber or red
CTG interpretation
(nice 2022)

47. 
• White
.
－ fewer than 5 contractions in 10 minutes
• Amber
－ 5 or more contractions in 10 minutes, leading to
reduced resting time between contraction.
Contraction

48. 
• White
－ stable baseline of 110 to 160 beats a minute
• Amber
－ increase in baseline fetal heart rate of 20 beats a minute or more
from the start of labour or since the last review an hour ago, or
－ 100 to 109 beats a minute, or
.
－ unable to determine baseline
• Red
－ below 100 beats a minute, or
－ above 160 beats a minute.
• lower baseline fetal heart rates are expected with post-term
pregnancies, with higher baseline rates in preterm pregnancies.
Baseline fetal HR

49. 
minor oscillations in the fetal heart rate Measure it by
*
estimating the difference in beat per minute between
the highest heart rate and the lowest heart rate .
• white
－ 5 to 25 beats a minute
•Amber
－ fewer than 5 beats a minute for between 30 and 50
minutes, or
.
－ more than 25 beats a minute for up to 10 minutes
variability

50. 
• Red
－ fewer than 5 beats a minute for more than 50
minutes, or
－ more than 25 beats a minute for more than 10
minutes, or
－ sinusoidal.

51. 
*Define decelerations as transient episodes when the
fetal heart rate slows to below the baseline level by
.
more than 15 beats a minute, lasting 15 seconds
• their timing (early, variable or late) in relation to the
peaks and duration of the contractions.
Deceleration

52. 
concerning characteristics of variable decelerations:
• lasting more than 60 seconds
• reduced variability within the deceleration
• failure or slow return to baseline fetal heart rate
• loss of previously present shouldering.

53. 
• White
－ no decelerations, or
－ early decelerations, or
－ variable decelerations that are not evolving to have
.
concerning characteristics

54. 
• Amber
－ repetitive variable decelerations with any
concerning
characteristics for less than 30 minutes, or
－ variable decelerations with any concerning
characteristics for more than 30 minutes, or
－ repetitive late decelerations for less than 30 minutes.

55. 
• Red
－ repetitive variable decelerations with any concerning
characteristics for more than 30 minutes, or
－ repetitive late decelerations for more than 30
minutes, or
－ acute bradycardia, or a single prolonged
deceleration lasting 3 minutes or more.

56. 
*Define accelerations as transient increases in fetal heart
rate of 15 beats a minute or more , lasting15 seconds or
.
more
*the presence of fetal heart rate accelerations, even with
reduced variability, is generally a sign that the baby is
healthy.
*the absence of accelerations on an otherwise normal
CTG trace does not indicate fetal acidosis.
Acceleration

57. 
Categorise CTG traces as follows, based on whether each of
the 4 features (contractions, baseline, variability,
decelerations) have been scored as white, amber or red:
:
• normal
－ no amber or red features (all 4 features are white).
• suspicious:
－ any 1 feature is amber.
• pathological:
－ any 1 feature is red, or
－ 2 or more features are amber.

58. 

59. 
*the use of early ultrasound dating reduces the incidence of
postterm pregnancy.
*Induction of labor after 41+ weeks reduces perinatal mortality
rates without increasing CS rates.
*Sweeping the membranes significantly reduces the incidence of
postterm pregnancy.
*The use of NST and labor assessment in monitoring postterm
pregnancy twice weekly is recommended in women who prefer
conservative management with fetal surveillance.
Key points

60. 