This document discusses induction of labor for post-term pregnancies beyond 40 weeks gestation. It notes that while post-term births do not harm the mother, the fetus is at increased risk of complications due to placental deterioration. Specifically, the risks of meconium aspiration, low Apgar scores, and birth injury are greater. The causes of post-term births are often unknown, though inaccurate dating increases the likelihood. Methods of monitoring the fetus to determine the need for induction include kick counts, CTG, biophysical profiles and Doppler flow studies. Natural, mechanical and pharmacological methods can be used to induce labor, though risks include uterine hyperstimulation and failed induction requiring C-section.

1. POST DATESPOST DATES
ANDAND
INDUCTION OF LABOURINDUCTION OF LABOUR
DR. ARIVENDRAN M.D ( UKM ) MRCOG (UK )

2. DEFINITION
• POSTDATES : Pregnancy after 40
weeks ( after EDD )
• POSTTERM : Pregnancy after 42
weeks ( EDD plus 14
days )

3. INTRODUCTION
• Post-mature births do not
have any harmful effects
on the mother;
however, the fetus
can begin to suffer
from malnutrition.
• After the 42nd week of
gestation, the placenta,
which supplies the baby
with nutrients and
oxygen from the mother,
starts aging and will
eventually fail.

4. • A number of key
morbidities are
greater in infants
born to postterm
pregnancies including
meconium and
meconium
aspiration,
neonatal
academia, low
Apgar scores,
macrosomia, and,
in turn, birth
injury

5. AETIOLOGY
• The causes of post-term births
is unknown.
• But post-mature births are
more likely when the mother
has experienced a previous
post-mature birth.
• Due dates are easily
miscalculated when the
mother is unsure of her last
menstrual period, so in reality
the baby is not technically
post-mature ( MOST
LIKELY )
• Post-mature births can also be
attributed to irregular
menstrual cycles.

6. TAKE HOME MESSAGETAKE HOME MESSAGE
• PLEASE ALWAYS TRY DO A DATING SCAN IN
THE FIRST TRIMESTER OR THE EARLIEST
OPPORTUNITY AVAILABLE
• A DATING SCAN IN THE FIRST TRIMESTER
IS ALWAYS MORE RELIABLE THAN HER
LAST MENSTRUAL PERIOD
• PLEASE CHECK THE PATIENT’S DATES
BEFORE INDUCING

7. SIGNS OF POST MATURITY
• Dry skin
• Overgrown nails, Creases on
the baby's palms and soles of
their feet,
• Minimal fat
• Brown, green, or yellow
discoloration of their skin

8. SIGNS OF POST MATURITY
• Some postmature babies will
show no or little sign of
postmaturity.

9. COMPLICATIONS OF POST DATES
FETAL RISKS
• Reduced placental perfusion
• Calcium is deposited on the
walls of blood vessels and
proteins are deposited on the
surface of the placenta
• Limits the blood flow through
the placenta and ultimately
leads to placental insufficiency
and the
• Fetus is no longer properly
nourished.

10. • OLIGOHYDARMNIOS
• MECONIUM
ASPIRATION
SYNDROME

11. MATERNAL COMPLICATIONS
• Increased incidence of
forceps assisted, vacuum
assisted or cesarean
• Difficulty in delivering
the shoulders, shoulder
dystocia, becomes an
increased risk.
• Increased psychological
stress
• Need for induction

12. METHODS OF MONITORING
FETAL MOVEMENT CHART
Regular movements of the baby
is the best sign indicating that
it is still in good health.
The mother should keep a "kick-
chart" to record the
movements of her baby.
If there is a reduction in the
number of movements it could
indicate placental
deterioration

13. METHODS OF MONITORING
CARDIOTOCOGRAPH
(CTG)
Electronic fetal
monitoring uses a
cardiotocograph to
check the baby's
heartbeat and is
typically monitored
over a 30-minute
period.

14. METHODS OF MONITORING
ULTRASOUND SCAN ( AFI )
If the placenta is deteriorating,
then the amount of fluid will
be low and induced labor is
highly recommended.
However, ultra sounds are not
always accurate
( operator dependant )
Actual placenta won't start to
deteriorate until about 48
weeks.

15. METHODS OF MONITORING
BIOPHYSICAL
PROFILE
A biophysical profile
checks for the baby's
heart rate, muscle tone,
movement, breathing,
and the amount of
amniotic fluid
surrounding the baby.

17. METHODS OF MONITORING
DOPPLER FLOW STUDY
Doppler flow study is a type of
ultrasound that measures the
amount of blood flowing in
and out of the placenta

18. TALKING POINTS FOR DISCUSSION
• WHAT IS THE REASON FOR THE INDUCTION ?WHAT IS THE REASON FOR THE INDUCTION ?
• WHAT ARE THE ALTERNATIVES TO INDUCTIONWHAT ARE THE ALTERNATIVES TO INDUCTION
INCLUDING WAITING ?INCLUDING WAITING ?
• WOULD I BE AT RISK OR WOULD MY BABY BE ATWOULD I BE AT RISK OR WOULD MY BABY BE AT
RISK ?RISK ?
• HOW DOES AN INDUCTION OCCUR ?HOW DOES AN INDUCTION OCCUR ?
• WHAT ARE THE RISKS OR SIDE EFFECTSWHAT ARE THE RISKS OR SIDE EFFECTS
ASSOCIATED WITH INDUCTION ?ASSOCIATED WITH INDUCTION ?
• WHAT IS THE NEXT STEP IF INDUCTION FAILS ?WHAT IS THE NEXT STEP IF INDUCTION FAILS ?

19. WHAT IS THE REASON FOR INDUCTION ?
• Women with uncomplicated pregnancies should
usually be offered induction of labour between
41+0 and 42+0 weeks to avoid the risks of
prolonged pregnancy.
• The exact timing should take into account the
woman’s preferences and local circumstances.

20. UNCOMPLICATED PREGNANCY
• Give women every
opportunity to go into labour
spontaneously.
• Offer membrane sweeps:
- to nulliparous women at 40
week antenatal visit
- to all women at 41 week
antenatal visit
- 1 week prior to women you
plan to induce
- if assessing the cervix.
• Offer induction between 41
and 42 weeks, depending
on woman’s preferences

21. EVIDENCED BASED PRACTICE
• Sweeping the membranes in
women at term reduced the
delay between randomisation
and spontaneous onset of
labour, or between
randomisation and birth, by a
mean of 3 days.
• Sweeping the membranes
increased the likelihood of
both spontaneous labour
within 48 hours

22. WHAT ARE THE ALTERNATIVES TO
INDUCTION INCLUDING WAITING ?
• Membrane sweeping reduced the frequency
of using other methods to induce labour (‘formal
induction of labour’).
• From 42 weeks, women who decline induction of
labour should be offered increased antenatal
monitoring consisting of at least twice-weekly
cardiotocography and ultrasound estimation of
maximum amniotic pool depth.

23. WOULD I BE AT RISK OR WOULD MY
BABY BE AT RISK ?
• The risk of Stillbirth
increases from
1/3000 ongoing
pregnancies at 37
weeks to 3/3000
ongoing pregnancies
at 42 weeks to
6/3000 ongoing
pregnancies at 43
weeks
• With routine
induction, perinatal
death was reduced
and the rate of
caesarean section was
reduced

24. HOW DOES AN INDUCTION OCCUR ?
•NATURAL METHODS
•MECHANICAL METHODS
•PHARMACOLOGICAL
METHODS

25. NATURAL METHODS
• CERVICAL
STRETCH AND
MEMBRANE
SWEEPING

26. NATURAL METHODS
• NIPPLE STIMULATION
• SEXUAL INTERCOURSE
• ACUPUNCTURE

28. MECHANICAL METHODS
• FOLLEYS CATHETER

29. MECHANICAL METHODS

30. MECHANICAL METHODS
• DILAPAN
• LAMINARIA
• HYDROPHILIC DILATOR

31. PHARMACOLGICAL METHODS
• PROSTIN
• DINOPROSTONE
• PROSTAGLANDIN E2

32. PROSTIN INDUCTION

33. WHAT ARE THE RISKS AND SIDE
EFFECTS ASSOCIATED WITH
INDUCTION ?
• UTERINE
HYPERSTIMULATION
• FETAL DISTRESS
• FAILED INDUCTION

34. WRITTEN CONSENT
• MEDICOLEGAL
• COMPULSARY

35. WHICH IS THE NEXT STEP IF
INDUCTION FAILS ?
• EXPECTANT
MANAGEMENT
• REINDUCTION
• LOWER SEGMENT
CASEREAN
SECTION

36. FAILED INDUCTION
If induction fails, the subsequent management
options include:
• – a further attempt to induce labour or to wait
(the timing should depend on the clinical
situation and the woman’s wishes)
• – caesarean section

37. BISHOP’S SCORE
• Bishop score, also Bishop's
score, is a pre-labour scoring
system to assist in predicting
whether induction of labour
will be required and be
successful
• The Bishop score grades
patients who would be most
likely to achieve a successful
induction

38. MODIFIED BISHOP SCORE
• According to the Modified
Bishop's pre-induction cervical
scoring system, effacement has
been replaced by cervical
length in cm
• Points are added or subtracted
according to special
circumstances as follows:
• One point is added for:
▫ 1. Existence of pre-eclampsia
▫ 2. Every previous vaginal
delivery
• One point is subtracted for:
▫ 1. Postdate pregnancy
▫ 2. Nulliparity (no previous
vaginal deliveries)
▫ 3. PPROM; preterm
premature (prelabor) rupture
of membranes

40. INDICATIONS FOR INDUCTION IN
HOSPITAL SEGAMAT
• POSTDATES 7 DAYS ( 41 WEEKS )
• GDM ON TREATMENT AT 38 WEEKS
• PIH ON TREATMENT AT 38 WEEKS
• GDM NOT ON TREATMENT / DIET CONTROL
AT EDD
• PROM AFTER 12 – 24 HOURS

41. LOCAL SETTING
• CONSENT TAKEN BY
MEDICAL OFFICERS IN
CLINIC OR ON
ADMISSION
• DAILY PROSTIN
INSERTION (max 3 doses)
• PRIMIDS – 3 mg,
• MULTIPS – 1.5 mg
• DONE IN THE WARD BY
MEDICAL OFFICERS

42. • CTG PRIOR TO PROSTIN INSERTION
• PREFERABLY AT 6 AM IN THE MORNING
THUS CTG POST PROSTIN CAN BE
REVIEWED DURING MORNING ROUNDS
• PREV LSCS AND GRANDMULTIPARA –
FOLLEY’S CATHETER ( kept for 24 hours )
• IF BISHOP SCORE FAVOURABLE >8, ARM
AND PITOCIN

43. THANK YOU FOR YOUR KIND
ATTENTION !!!!