- Induction of labor is recommended for post-term pregnancies (greater than 42 weeks) due to increased risks of complications. Risks increase further as pregnancy progresses beyond 42 weeks. - For low-risk pregnancies between 41-42 weeks, induction can be considered but is not necessarily recommended since perinatal outcomes do not significantly differ from 40-41 weeks. The risks and benefits should be discussed with the patient. - Fetal surveillance with non-stress tests and ultrasound amniotic fluid measurements twice weekly is recommended for pregnancies beyond 42 weeks declining induction. Delivery is recommended if any test results cause concern for the fetal environment.

1. Benha University Hospital,
Egypt
elnashar53@hotmail.com
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3. Postterm pregnancy: pregnancies that last longer
than 42 weeks.
Postdate pregnancies: pregnancies that last longer
than the estimated date of confinement, (ie, 40 wk).
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5. At 40 w only 58% had delivered.
By 41 w: 74%
By 42 w: 82%.
Postterm pregnancy(>42W):
16%. (12%)
Pregnancies >41: 26%
Postdate pregnancy >40W:42% (NICE)
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7. Both postterm and postdate pregnancy is
inaccurate dating criteria.
Ultrasound dating is inaccurate for a patient
who presents late in pregnancy
An ultrasound before 20 w reduces the need
for induction for post term pregnancy
(NICE,A)
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8. CRL: ±3-5 days,
ultrasound at 12-20 w:±1 week,
at 20-30 weeks:±2 w
after 30 weeks: ±3 w.
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11. • In high risk pregnancy
• nonreassuring surveillance,
• oligohydramnios,
• growth restriction,
• certain maternal diseases,
The risks of remaining pregnant
outweigh the risks of delivery
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12. Diabetes in pregnancy
fivefold increase in perinatal mortality
rate: induction of labour prior to their
estimated date for delivery.
(NICE C)
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13. Elective induction of labor at or after 39 W in
the absence of documented lung maturity
provided that
1. 36 w after a positive hCG test
2. 20 w after fetal heart tones have been
established by a fetoscope or
3. 30 w by a Doppler examination, or
4. 39 w’ have been established by a CRL or
5. by an ultrasound performed before 20 w
consistent with dates by the LMP.
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14. B. In the low-risk pregnancy.
•The certainty of gestational age,
•cervical examination findings,
•estimated fetal weight, and
•past obstetrical history
•Involving the patient in this discussion
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15. Inducing labor at 41 weeks’ gestation in
an accurately dated, low-risk
pregnancy, regardless of cervical
examination findings.
1. Averts the need for antepartum fetal
surveillance and
2. does not increase the cesarean
delivery rate; in fact, it may decrease
the cesarean delivery rate.
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16. 3. Perinatal morbidity and mortality do
not increase appreciably between 40-41
weeks of gestation;
4. Several complications are associated
with postterm pregnanciesa.
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17. a.macrosomia, shoulder dystocia, and
cephalopelvic disproportion
b.perinatal mortality increases
c.risk of stillbirth increases from
1 per 3000 ongoing pregnancies at 37
weeks to
3 per 3000 ongoing pregnancies at 42
weeks to
6 per 3000 ongoing pregnancies at 43
weeks.
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18. 5. increasing the risk for cesarean
delivery with a failed induction is far
less likely in the era of safe and
effective cervical ripening agents.
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19. #A meta-analysis by Grant reviewed 11
trials and concluded that a policy of
routine induction had a lower rate of
perinatal morbidity and cesarean
delivery, demonstrating both fetal and
maternal benefit compared to
expectant management.
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20. #A recent review in the Cochrane
Library concluded that routine induction
in low-risk pregnancies at or after 41
weeks’ gestation is associated with a
reduction in perinatal mortality, with no
increase in the rate of instrument
deliveries or cesarean delivery.
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21. In summary, routine induction at 41
weeks’ gestation does not increase the
cesarean delivery rate, and may
decrease it, without negatively affecting
perinatal morbidity or mortality.
In fact, there may be both maternal and
neonatal benefits to a policy of routine
induction of labor in well-dated low-risk
pregnancies at 41 weeks’ gestation.
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22. A policy of induction of labour prior to 41
weeks would generate an increase in
workload without reducing perinatal
mortality
(NICE).
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23. •>42 wk : should be used
•before 41 weeks: not used, not improve
outcome
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24. From 42 weeks women who decline
induction of labour should be offered
increased antenatal monitoring consisting of
a twice weekly CTG and ultrasound
estimation of maximum amniotic pool depth.
(NICE A)
A modified biophysical profile consisting of a
nonstress test and an amniotic fluid index
have been shown to be as sensitive as a full
biophysical profile.
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25. 1.An amniotic fluid index of more than 8
cm and
2. a reactive fetal heart rate tracing are
reassuring.
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26. 3. If the tracing remains nonreactive,
a. A contraction stress test or
b. a full biophysical profile. These may also
be used if the tracing is reactive but shows
fetal heart rate decelerations.
However, in the pregnancy that is beyond 41
weeks of gestation, the threshold for
delivery should be very low.
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27. In summary, the use of a nonstress test and
an amniotic fluid index 2 times per week for
postterm, not postdate, pregnancies may
decrease fetal mortality.
In addition, if any indication during
antepartum surveillance leads the
practitioner to question the intrauterine
environment, delivery should be the rule.
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29. Once the decision to deliver a patient
has been made, the route of delivery
and the specifics of intrapartum
management depend on
individual circumstances,
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30. Where?
Risk factors (e.g.suspected fetal
growth compromise, previous
caesarean section and high parity): C
The induction process should not occur
on an antenatal ward.
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31. HOW?
80% of patients who reach 42 weeks’
gestation have an unfavorable cervical
examination finding (ie, Bishop score
<7)
(Harris, 1983).
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32. A.chemical
1. prostaglandin E1 tablets for oral or
vaginal use,
2. prostaglandin E2 gel for intracervical
application, and
3. a vaginal insert containing 10 mg of
dinoprostone.
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33. Oxytocin compared to prostaglandins for
induction of labour
Prostaglandins should be used in preference
to using oxytocin when induction of labour is
undertaken in either nulliparous or
multiparous women with intact membranes
regardless of their cervical favourability.A
Either prostaglandins or oxytocin may be used
when induction of labour is undertaken in
nulliparous or multiparous women who have
ruptured membranes, regardless of cervical
status,as they are equally effective. A
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34. Comparison of different regimens of oxytocin
administration
Oxytocin should not be started for 6 hours
following administration of vaginal
prostaglandins. C
In women with intact membranes amniotomy
should be performed where feasible prior to
commencement of an infusion of oxytocin. C
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35. B. mechanical.
1. Membrane sweeping or stripping
2. Foley balloon catheters placed in the
cervix
(Sullivan, 1996),
3. extra-amniotic saline infusions, and
4. laminaria: effective
(Guinn, 2000).
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36. .
Membrane sweeping
Prior to formal induction of labour, women
should be offered sweeping of the
membranes. A
-is not associated with an increase in
maternal or neonatal infection.
-is associated with increased levels of
discomfort during the procedure and
bleeding.
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37. EFM
Management of complications
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38. Intrapartum fetal monitoring: EFM
If the fetal heart rate tracing is equivocal,
a. fetal scalp stimulation,
b. fetal scalp blood sampling, and/or
c. fetal pulse oximetry
d. If the practitioner cannot find reassurance
that the fetus is tolerating labor, cesarean
delivery is recommended.
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39. •Management of complications
presence of meconium, macrosomia,
and
fetal intolerance to labor.
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40. A.meconium.
{increased uteroplacental insufficiency,
which leads to hypoxia in labor and
activation of the vagal system}.
1. amnioinfusion of isotonic sodium
chloride solution and 2. suctioning of
the oropharynx and nose upon
delivery of the head
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41. B. Fetal macrosomia can lead to maternal and
fetal birth trauma and to arrest of both first-
and second-stage labor. Recognizing the
limitations of ultrasound at term, it is still
advisable to obtain
1.an estimated fetal weight prior to induction
of the postdate pregnancy.
2. mid-pelvic instrument deliveries should not
be attempted.
3. delivery plan is being prepared for shoulder
dystocia
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42. C. uterine hypercontractility with a suspicious
or pathological cardiotocograph (CTG),
secondary to oxytocin infusions,
1. the oxytocin infusion should be decreased or
discontinued.B
2. In the presence of abnormal FHR patterns
and uterine hypercontractility (not secondary
to oxytocin infusion) tocolysis should be
considered. A suggested regime is
subcutaneous terbutaline 0.25 milligrams.
A
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43. D. suspected or confirmed acute fetal
compromise, delivery should be accomplished
as soon as possible, taking account of the
severity of the FHR abnormality and relevant
maternal factors. The accepted standard has
been that ideally this should be accomplished
within 30 minutes. B
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