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Post term pregnancy, Perinatal Loss - Coggle Diagram

- - - - Preeclampsia ≥ 37 weeks, post-dates or post-term pregnancy, uncomplicated dichorionic twin pregnancy at >38 weeks, IUGR, gestational diabetes, oligohydramnios, PROM, gestational hypertension at ≥ 38 weeks
    - - Prostaglandin gel or insert, amniotomy if the cervix is favourable, oxytocin, misoprostol in some units
- - - - maternal age over 35
      - maternal infections
      - poor nutrition
      - lifestyle factors such as smoking and obesity (modifiable)
      - Gestational diabetes is also a recognized cause of stillbirth
    - - induction at 39-40 weeks for women over age 35.
- - - - no routine interventions
      - freedom of movement
      - continuous labour support
      - spontaneous pushing
      - labour begins on its own
      - no separation of mother and baby
      - IOL
        
        With an IOL, labour has not started on its own, there is increased likelihood of other interventions such as artificial rupture of membranes (ARM) and epidural analgesia, and freedom of movement may be limited due to the need to continuous fetal monitoring.
- - - - When a pharmacological or mechanical method is used to soften, efface, or dilate the cervix prior to induction of labour (IOL), in order to increase the likelihood of a successful vaginal delivery.
- - - - Reduced blood flow from the placenta can lower the baby’s oxygen reserves. During induction of labour, strong, long, or frequent contractions—often caused by oxytocin—can use up the baby’s remaining oxygen.
      - FHR
        
        The reduced amniotic fluid volume and decreased Wharton’s jelly around the cord makes the cord more vulnerable to cord compression during labour which would be seen as variable decelerations on the fetal heart tracing.
        
        Minimal FHR variability and late decelerations may be seen on the fetal heart tracing as a result of reduced placental perfusion.
- - - - It is a normal physiologic function that occurs with maturity or with breech presentation.
      - It is the result of hypoxia-induced peristalsis and sphincter relaxation.
      - It may be a sequel to umbilical cord compression induced vagal stimulation in mature fetuses.
    - - meconium aspiration includes:
        
        airway obstruction
        
        atelectasis and air trapping
        
        inflammatory response and chemical pneumonitis
        
        inhibition of surfactant function
        
        increased pulmonary vascular resistance and development of persistent pulmonary hypertension
    - - Intrauterine hypoxia may lead to the passage of meconium in utero, which then leads to increased risk of meconium aspiration syndrome.
      - Meconium aspiration syndrome (MAS) does not occur in every fetus/infant who is born in meconium stained fluid
    - - An assessment of the overall clinical picture including gestational age, pregnancy risk factors, labour history and progress, and interpretation of fetal health surveillance data assists you to anticipate the possible condition of the neonate at time of delivery.
      - When there is meconium present in the amniotic fluid, newborn resuscitation guidelines recommend that the infant still receive initial steps of Newborn Resuscitation Program (NRP) with its mother.
      - Treatment
        
        Treatment for MAS is aimed at improving oxygenation.
        Warmed, humidified oxygen may be all that is needed; however, mechanical ventilation or continuous positive airway pressure (CPAP) is required for 30%-50% of infants with MAS
        
        Because these infants are term or post-term, they may require paralysation in order to decrease their resistance to ventilation.
        Infants with MAS are at increased risk for cerebral palsy, developmental delays, and long-term pulmonary problems.
        
        With new treatments, the mortality rate of MAS has decreased to less than 5%.
  - - - The postmature infant has decreased subcutaneous fat and lacks lanugo and vernix
      - dry, cracked, peeling skin; long nails; and meconium staining of skin, nails, and umbilical cord
      - Placental insufficiency also increases the risk of hypoxemia, meconium stained amniotic fluid, and meconium aspiration
- - - - separating the membranes from the cervix and lower segment of the uterus by sweeping the finger 360 degrees during a vaginal exam.
      - it could be done as often as once a week
- - - - Once regular moderate to strong contractions are evident, there is no need to continue to increase the oxytocin. over a prolonged period of time can result in oxytocin receptor desensitization which results in the oxytocin being less effective
    - - The Cue is the classification of normal, atypical, or abnormal
      - Judgement phase would include a review of any risk factors the woman has, the physiologic status of the fetus and mother, the stage and progress of her labour, and performing any additional assessments to develop a comprehensive picture of what is going on. Additional assessments would include vital signs, palpating the abdomen, assessing fluid balance and medication use in labour, and considering all possibilities for what you are seeing
      - Your response, which is the Decision phase, will be guided by your assessment data and your interpretation of the data. Responses for atypical and abnormal tracings are outlined in the FHS guideline
- - - - fetal mortality, neonatal mortality, and infant death as follows:
        
        Neonatal mortality rate: death when <28 days of life. Rate 3.5-4.0 per 1,000 births (low of 2.3 in PEI to high of 8.5 in Nunavut)
        
        Infant mortality: death in the first year of life is 4.9-5.4 per 1,000 births (low of 3.6 in PEI to high or 17.9 in Nunavut)
        
        Fetal mortality: death in a fetus >500 gm or >20 weeks gestation. Rate 7.5-8.1 per 1,000 total births (13.5 among multiples)
  - - - impact the couple’s relationship and future pregnancy plans
        
        Women may want to start discussing future pregnancy right away, while their partner may be more hesitant to try again
        
        Men describe feeling the need to put their own grief aside in order to support their partner
      - When there is a clear reason for the loss, such as a congenital anomaly, it can assist the woman/family to make sense of things; however, if the reason is unknown, the transition through grief may be more challenging.
      - experience shock, disbelief, anger, and possibly guilt
        
        to blame other members of the health care team or feel that they are blaming us