SPONTANEOUS VAGINAL

DELIVERY
IN
Presented by
POST
TERM
PREGNANCY
Jane A. Djianzonie
100 100 128
R. Pavin Vikneshwaran

100 100 185

Advisor
dr. Fadjrir, M.Ked (OG), Sp.OG
Mentor
dr. Rina Sinta Dhanu
SMF ILMU OBSTETRI DAN
GINEKOLOGI
RSU DR. PIRNGADI MEDAN
2015

INTRODUCTION

INTRODUCTION

INTRODUCTION

INTRODUCTION

INTRODUCTION
In postterm pregnancy there are changes in
placenta, amniotic fluid and fetal
circumstances oligohydramnios,
meconium aspiration, asphyxia fetus and
shoulder dystocia increase the risk of poor
perinatal outcome increased perinatal
mortality
Risk for mothers with postterm pregnancy
consist of postpartum bleeding and
increased obstetric action.

THEORY
Spontaneous
Vaginal

Spontaneous Vaginal Delivery

The First stage: stage of cervical

effacement and dilatation
Definition: the first stage of labour
refers to the period from the onset of
true uterine contractions to the fully
dilation of the cervix, when the
diameter of the cervical os measures
10cm.

Spontaneous Vaginal Delivery

Duration:
o primigravida = 8-12 h
o multigravida = 6-8 h
Phases of the first stage:
Latent phase: started when the cervix
dilatated slowly and reached to about
3cm.
A. in primigravida = 8h
B. in multigravida = 4h
. - Active phase: rapid dilatation of the
cervix to reach 10cm
A. in primigravda = 4h
B. in multigravida =2h

Spontaneous Vaginal Delivery

The active phase is divided into:

1. Accelerative phase 2 hr
2. Slopping phase 2 hr
3. Decelerative: 2 hr
N.B in primigravida
the cervix dilates
from above
downwards, in
multigravida
dilatation of the
internal os, taking up
of the cervix and
dilatation of the
external os occurs
simultaneously.

Spontaneous Vaginal Delivery

II-The Second stage of labour:

stage of delivery of the fetus.
Definition: the second stage of labour
refers to the period from complete
cervical dilatation to the birth of the
fetus.
Duration:
A.in primigravida =1 h
B.in multigravida = h
however the timing of the second
stage is very different to determine
and controversial and can be extended
as much as there is progress in descent
and no harm to the mother or fetus

Spontaneous Vaginal Delivery

Cardinal sign of
delivery
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Delivery of the fetal's
shoulder (expulsion)

Spontaneous Vaginal Delivery

Spontaneous Vaginal Delivery

Spontaneous Vaginal Delivery

Spontaneous Vaginal Delivery

Delivery of Shoulder
After
Rotation

external

sides of the head are

grasped
with
two
hands, and gentle
downward traction is
applied
until
the
anterior
shoulder
appears under the
pubic arch
Next, by an upward
movement,
the
posterior shoulder is
delivered
The rest of the body
almost
always

Spontaneous Vaginal Delivery

Clamping the cord

4-5 cm , 2-3 cm fetal abdomen
two clamps
Plastic cord clamp

Spontaneous Vaginal Delivery

Signs of placental separation

1.

uterus becomes globular

firm.

2.

Sudden gush of blood.

3.

Uterus rises (placenta

separated , passes dawn to
lower u-segment.

4.

Umbilical cord protrudes

farther out of the vagina.

Third Stage Delivery of

the Placenta
Active management of third
stage
oxytoxin injection in 1
minute after baby delivery
(10 IU intramuscular at
lateral vastus muscle).
Controlled umbilical cord
taut.

Spontaneous Vaginal Delivery

Fourth stage of labor

Exam placenta , membranes ,
umbilical cord
Completeness , anomalies
Hour immediately fallowing
delivery is Critical fourth stage
of labor
uterine atony , BP , pulse every 15

THEORY

Post Term Pregnanc

POST - TERM

DEFINITION
The international definition of prolonged
pregnancy, endorsed by the American
College of Obstetricians and Gynecologists
(2004), is 42 completed weeks (294 days)
or more from the first day of the last
menstrual period. It is important to
emphasize the phrase 42 completed
weeks. Pregnancies between 41 weeks 1
day and 41 weeks 6 days, although in the
42nd week, do not complete 42 weeks until
the seventh day has elapsed.

POST - TERM

INSIDENCE
Approximately 7% of the 4 million
babies born in the United States in
2001 is estimated to have been born at
42 weeks or more. Analysis of 27 677
women born in Norway, an increase of
10% to 27%, if the first birth postterm
and to 39% if the twice-born postterm.

POST - TERM

Etiology
Effects of Progesterone
progesterone sensitivity of uterus to oxytocin

The theory of oxytocin

release of less oxytocin from the neurohypophysis pregnant
women on advance gestational age is suspected as a factor in
postterm pregnancy

Theory of Cortisol / fetus ACTH

Fetal cortisol placenta progesterone & estrogen

prostaglandin
anencephaly, fetal adrenal hypoplasia and absence of the pituitary
gland prod cortisol postterm

Uterus Neural

pressure on the cervical ganglion of Frankenhauser plexus will

excite uterine contractions
location abnormality, short umbilical cord and the lower part is still
high

Hereditary

mother gave birth to a daughter postterm, it is probable that her

daughter will become postterm pregnant

POST - TERM

Diagnosis
Menstrual history
History of antenatal care
Pregnancy test
Fetal movement
Fetal heart rate

Position of uterine fundus

Ultrasonography (USG) Examination
The earlier ultrasound examination performed, then the
pregnancy age is obtained will be more accurate

Radiological examination
Examination of amniotic fluid
Levels of Lecithin / spingomielin
Amniotic fluid Tromboplastin activity (AFTA)
Amniotic fluid cytology

POST - TERM

POST - TERM

Changes in Post Term

Pregnancy
Changes in amniotic fluid
Changes in the placenta
Changes in the fetus
Fetal weight
postmaturitas syndrome
Fetal distress or perinatal death
The influence to the mother
Morbidity / mortality of mothers
emotional aspects

POST - TERM

Postmaturity Syndrome

POST - TERM

POST - TERM

Postmaturity Syndrome

POST - TERM

Management

POST - TERM
Treatment

POST - TERM

CASE REPORT

CASE REPORT

PATIENTS
IDENTITY
Name

: DR

Age

: 23 years old

Religion
Race

: Christian
: Batak

Occupation

: Housewife

Education : High school (SMA)

MR Num. : 97.11.83
Admission Date

: 11 August 2015

CASE REPORT

History Taking
Mrs DR, 23 yo, G1P0A0, Christian, Batak, Housewife, wife from
Mr.H, 33yo, private servant, came to ER with :
Chief complaint : exited expected date of delivery (EDD).
Strain on labor (-), History of bloody show (-), Histoy of amniotic
Fluid Leakage (-)
History of previous disease : History of previous med : Menstrual History
LNMP : 19/10/2014
EDD

: 26/07/2015

ANC

: Midwife 2x and SpOG, 4x.

History of Labor
1. This pregnancy

CASE REPORT

Status Present
Sens : CM
BP

Anemis : -

: 120/80mmhg

Icteric : -

HR

: 90 times /second

Cianoteic

:-

RR

: 20 times /second

Dyspneu

:-

Temp : 36,5C

Oedem : -

Obstetrics Status
Abdomen

: asymetric enlargement,

Fundal height

: 4 fingers below proc. Xypoid(31 cm)

Tension Part

: Left

Lowest Part

: head presentation

Fetal Heart Rate(FHR)

: 130 x/i, Reguler

Fetal Movement (FM)

: (+)

Uterine Contraction

: (-)

Estimated Birth Weight : 3000-3200gr

CASE REPORT

Clinical Pelvic Assessment

- Sacral Promontory : not palpable
- Shape of sacrum
- Ischial spine
- Pubic arch
- Os. Coccygeus

: Concave
: not prominent

: Blunt
: mobile

Conclusion : pelvic adequate

Vaginal Examination (VT) : Cervix closed in tight.

CASE REPORT

USG TAS
- Single Fetus, Head Presentation, Alive Fetus
- Fetal Movement (+)
- Fetal Heart Rate (FHR) (+)
- Biparietal Diameter : 96mm
- Femur Length : 84mm
- Abdominal Circum. : 342mm
- Placenta Anterior Corpus, Calcification (+)
- Amniotic fluid (+) normal range (150mm)
- Estimated Fetal Weight : 3000-3200
Conclusion :
Single Fetus + Intra uterine pregnancy (42-43

CASE REPORT

Results

Normal Values

4,10 g%

12-14

Erytrocyte

2,78 x106/mm3

4,5-5,5

Leucocyte

12.8 x103/mm3

4.000-10.000

16,3 %

36-42

164 x103/mm3

150-440 x 103

MCV

58,60 fL

80-97

MCH

14,70 pg

27-33,7

25,20 g/dL

31,5-35

22,90 %

10-15

Hb

Ht
Thrombocyte

MCHC
RDW
Protrombin time
-

Patient
Control

INR
APTT
-

Patient
Control

13,0 detik

15,5 detik
1,03

32,3 detik

AST/SGOT

33,4 detik
22,00 U/L

0-40

SGPT

12,00 U/L

0-40

Glucose Ad Random

92,0 mg/dL

<140 mg/dL

Ureum

20,0mg/dL

10-50 mg/dL

Creatinin

0,66mg/dL

0,60-1,20 mg/dL

Total Bilirubin

0,50

0,00-1,20 mg/dL

Direct Bilirubin

0,17

0,05-0,30 mg/dL

CASE REPORT

Diagnosis
Primi Gravida + Intrauterine Pregnancy (42 weeks
2days) + Head presentation + Alife Fetus + Non
Inpartu + Anemia

Therapy
- IVFD RL 20 drips/i

Planning
Improved general condition of the patient.
Transfusion 3 bag (PRC) , a routine blood test is
done 6 hours post-transfusion.
Consult Internal Medicine for Anemic diagnostic
confirmation and tolerance of transfusion.

Date

CASE REPORT

11
2015

Date
12

August S O Sens: compos mentis

2015

August S O Sens: compos mentis

BP : 120/80 mmHg

BP : 120/80 mmHg

HR : 82x/I reguler

HR : 82x/I reguler

RR : 20x/I reguler

RR : 20x/I reguler

T : 36,5C

T : 36,7C

Anemis: + / +, Icteric : - / -, Cyanosis: -,

Anemis: + / +, Icteric : - / -, Cyanosis: -,

Dyspnea:- Edema: -

Dyspnea:- Edema: -

Obstetric Status

Obstetric Status

Abdomen : Enlarged, Asymmetry

Abdomen : Enlarged, Asymmetry

Fetal Movement : (+)

Fetal Movement : (+)

Uterine Contraction : (-)

Uterine Contraction : (-)

Fetal Heart Rate : 146 x/i, regular

Fetal Heart Rate : 146 x/i, regular

Vaginal Bleeding : (-)

Vaginal Bleeding : (-)

Defecation and urination (+) normal.

Defecation and urination (+) normal.

A Primi Gravida + IUP(42 weeks, 2 days)

+ HP + AF + non inpartu + Anemia

P IVFD RL 20 gtt/i
Planning :
-

Monitor Vital Sign, FHR, Uterine

Contraction

Transfusion PRC 3bag

A Primi Gravida + IUP(42 weeks, 3days) + HP +

AF + non inpartu + Anemia

P IVFD RL 20 gtt/i
Planning :
-

Monitor
Vital
Sign,
FHR,
Uterine
Contraction
Transfusion PRC 2-bag, remainder 1bag.
Internal Medicine Consultation :
Screening blood test on Fe Serum
and TIBC test.

CASE REPORT

Date

13

August S

2015

Sens: compos mentis

BP : 120/80 mmHg

RR : 20x/I reguler

HR : 88x/I regular

T : 36,6C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: Obstetric Status

Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (-)
Fetal Heart Rate : 148 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.
Blood Test Result (Post Blood Transfusion)
Hb/ Ht/ Leu/ Plt

: 6,50 / 23,10 / 14.900 / 127.000

Fe Serum/ TIBC

: 23.00 / 619.000

Internal Medicine Consultation : Iron Deficiency Anemia

A
P

Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia
IVFD RL 20 gtt/i
Planning :
-

Monitor Vital Sign, FHR, Uterine Contraction

Transfusion PRC 1bag
Blood Test Post Blood Transfusion

CASE REPORT

Date
14

August S

Straining to give birth

2015

0900

WIT

Sens: compos mentis

BP : 120/80 mmHg

RR : 21x/i reguler

HR : 88x/i, regular

T : 36,6C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:- Edema: -

Obstetric Status
Abdomen : Enlarged, Asymmetry
Fetal Movement : (+)
Uterine Contraction : (+), 2 x 10/10
Fetal Heart Rate : 148 x/i, regular
Vaginal Bleeding : (-)
Defecation and urination (+) normal.

Vaginal Toucher
Cervix : Axial, Dilation : 5cm, Effacement : 100%, occiput ??, Station of vertex (H II-III),
Amnion Sac : (+) Bulging
Glove: bloody show (+), Amnion fluid (-).

Primi Gravida + IUP(42 weeks, 4days) + HP + AF + non inpartu + Iron Deficiency Anemia

IVFD RL 20 gtt/i
Planning :
Monitor Vital Sign, FHR, Uterine Contraction
Spontaneus Vaginal Delivery
Partography Assessment on the progress of the delivery process.

CASE REPORT

0930

c c c c c

- - - - -

09.0 10.0 11.0

0
0
0

R
L

R
L

R
L

36 37 3737 37

DR
14 /08/ 15

23 tahun 1
0900

CASE REPORT

Spontaneus Vaginal Delivery with Vacuum Extraction

Report
At 14th August 2015
A Baby Girl Born, BW : 3100 gr, Neonatal Lenght : 49 cm, A/S : 8/9,
anus (+)
Mother was laid on the gynecology table with lithotomy position.
Emptying the bladder and cleaning the genital area was done.
Intravenous catheter is fixed well.
Head of the baby can be seen at vaginal introitus, evaluations of
occiput is at 12. Do the insertion of small size silicon vacuum cup
on the occiput. Evaluate wall of the vagina and cervix, is not
narrow. Carried out vacuum in conjunction with adequate
straining of the mother. Vacuum pressure lowered from 0.2, 0.4
and 0.6. Evaluation, the babys head have entered the vaginal
introitus. With a controlled pull in the direction of the birth canal,
head of baby was born, the vacuum cup is released, then carried
bipariental grip of baby head. The head pulled downward to give
birth to the front shoulder, pulled upward to release the back
shoulder.
A baby girl is born, BW : 3100gr, neonatal length : 49cm A/S: 8/9,
anus (+)

CASE REPORT

Neonatal
Assessment

Post Term
Syndrome

Type of Birth : Single baby

Dry skin(Patchy Skin): (+)

Date of Birth : 14 August 2015,

Skin
wrinkles
(+),Dominant Palm
and Soles

1130 WIT
circumstances of birth : Alive baby,
spontaneous cry.

Skin color

: (+), Pale

APGAR score : 8/9

Long nails : (+)

Sex

Lenugo

: female

Body Weight : 3100gr

Vernix Caseosa : (-)

Body Length : 49cm

Head Circumference
Trauma

: (-)

: 33cm

: not found

Congenital Abnormalities: not found

Long hair

: (+)

Skin maceration

: (-)

Meconium apiration: (-)

CASE REPORT

Therapy Post Delivery

- IVFD RL + Oxytocin 10-10-5-5 UI 20 drips/i
- Cefadroxil 2 x 500mg
- Mefenamat Acid 3 x 500mg
- Metargin 3 x 1tab

Planning
Transfusion 1 bag PRC
Routine blood test is done 6 hours post-transfusion.
Monitoring Vital Sign, Uterine Contraction and Post
partum haemorrhage.

CASE REPORT

Time
(hours) WIT
Heart Rate
Blood

13.00 13.15 13.3

84

14.15

14.45

15.15

84

80

90

82

120/70 130/9 120/9 130/90 130/80 120/80 130/80

Pressure
(mmHg)
Respiratory

80

0
88

13.45

22

22

20

20

20

20

20

Kuat

Kuat

Kuat

Kuat

Kuat

Kuat

Kuat

10

Rate
Uterine
Contraction
Bleeding
( in cc)

CASE REPORT

Date
15

August S

2015

Sens: compos mentis

BP : 120/80 mmHg

RR : 21x/i reguler

HR : 88x/i, regular

T : 36,6C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -

Localized Status
Abdomen

: Soepel, Peristaltic (+) normal

Fundus height

: 2 finger below the umbical

Vaginal Bleeding

: (-) lochia (+) Rubra

Urination

: (+) normal.

Defecation

: (-), Flatus (+)

Blood Test Result (Post Blood Transfusion 1bag)

Hb/ Ht/ Leu/ Plt

: 9,00 / 30.000 / 13.100 / 92.000

Post Vaginal Delivery on the indication of occiput anterior position + post partum day 1

Cefadroxil
2 x 500mg
Mefenamat Acid 3 x 500mg
Methargin
3 x 1 tab
B- Complex Vitamin
2 x 1 tab

CASE REPORT

Date
16

August S

2015

Sens: compos mentis

BP : 120/80 mmHg

RR : 20x/i reguler

HR : 80x/i, regular

T : 36,5C

Anemis: + / +, Icteric : - / -, Cyanosis: -, Dyspnea:-, Edema: -

Localized Status
Abdomen

: Soepel, Peristaltic (+) normal

Fundus height

: 2 finger below the umbical

Vaginal Bleeding

: (-) lochia (+) Rubra

Urination

: (+), normal.

Defecation

: (+), normal

Post Vaginal Delivery on the indication of occiput anterior position + post partum day 2

2 x 500mg
Cefadroxil
Mefenamat Acid 3 x 500mg
2 x 1 tab
B- Complex Vitamin
Planning :
Discard today. Control Obstetric Polyclinic as outpatient on the 20th August
2015.

TIME LINE

15 & 16 August 2015

11 August 2015
Patient is monitor after the
- Chief Complaint : Post
delivery.
Date!!!!
Patient is stable and getting
- Lab Test : Anemic : 4.10gr%
better.
- Fetus in normal condition
Discard
today.
Control
- Plan for blood transfusion
Obstetric
Polyclinic
as
(3bags)
outpatient on the 20th
- Consult internal medicine
August 2015.
for diagnostic & blood
transfusion tolerance
14 August 2015
12 August 2015
- Straining to give birth
- Transfusion for 2bag
- Hb : 9,00gr%
- Check lab 6 hours post
- Mother delivered at 1132
transfusion.
- Answer
from
the
WIT,
,3100gr, BL: 49cm,
consultant from internal
HC: 33cm
medicine : check for Fe
Patient stabil postpartum
13 August 2015
Serum & TIBC
- Hb : 6,50
- Fe/TIBC : 23.00/619.00
- Transfusion 3rd bag and
check lab 6hours post
transfusion
- Answer
from
the
consultant from internal
medicine : Iron deficiency
Anemia.

CASE
DISCUSSION

CASE DISCUSSION

Theory

In this Case?

Defination of Post Term is

prolonged
pregnancy,
endorsed by the American
College of Obstetricians
and Gynecologists (2004),
is 42 completed weeks
(294 days) or more from
the first day of the last
menstrual period.

This patient is completed

42weeks,
where
the
gestational age is 42weeks
and 2days.

Post term diagnosed with :

1. History Taking
Menstrual History
Last normal
Menstrual
Period (LNMP)
Expected
delivery date
(EDD).

Menstrual History

2. USG TAS
Gestational Age
AFI <10cm
Calcification of
Placenta

Result from USG TAS :

AFI : 15cm
IUP : 42 43 weeks with
calcification of placenta
gr.II.

LNMP

: 19/10/2014

EDD: 26/07/2015
Patient came to ER on the
11th August 2015
Gestational Age :
(42weeks, 2days)

CASE DISCUSSION

Theory

In this Case?

Post Term Syndrome there

will be changes in fetus like
:
Dry
skin
(+),
Skin
wrinkles(+) , Skin will
decolorized
as
the
meconium color, Long nails
(+) , Lenugo (-), Vernix
Caseosa (-), Long hair (+),
Skin
maceration
(+),
meconium aspiration (+).

Dry skin (Patchy Skin) : (+)

Skin wrinkles : (+),Dominant Palm
and Soles
Skin color
: (+), Pale
Long nails
: (+)
Lenugo
: (-)
Vernix Caseosa : (-)
Long hair
: (+)
Skin maceration : (-)
Meconium aspiration : (-)

CASE PROBLEMS

CASE
PROBLEMS ?
Whether the treatment in this case
was appropriate ?
The extent of general practitioners
can do, to handle the post term
pregnancy ?

Terima Kasih!