Subject: Post Dates Care
POLICY: All Clients will be monitored carefully when they pass their Estimated Due Date to ascertain the health of mother and fetus and the wisdom of continuing the pregnancy.
DEFINITIONS: When a pregnancy continues past the estimated due date it is considered to be post dates. This is a normal occurrence and is not, by itself, an indicator of increased risk. When a pregnancy continues past 42 weeks it is considered to be post term. This is a more rare condition and can be an indicator or increased risk to mother and infant. Post maturity is used to describe the features of a neonate who appears to have been in-utero longer than 42 weeks of gestation. These features were originally described by Clifford (1954) and consist of 3 stages:
· 1 - wrinkled, peeling skin, with thin body
· 2 - stage 1 and fetal distress, meconium present
· 3 - stage 1 & 2, findings with meconium stained skin or nails
The risks of post maturity include: macrosomia, poor tolerance of labor, placental insufficiency, fetal weight loss, ossification of fetal skull, low amniotic fluid levels, and increased meconium staining.
GUIDELINES: 1. The midwife will be aware that the client is still within normal limits and will refrain from frightening the client about her post dates status. The client will be informed of the difference between post dates and post maturity and encouraged to be patient and attend all testing scheduled at The Birth Center to rule out post maturity of her fetus.
2. When a client passes her EDD all pertinent dating information will be reviewed.
3. Vaginal exams will be performed noting dilation, effacement, station, position and compared with prior exams. Bishops score will be assigned.
4. A client will have clinical exams scheduled for 40 weeks, 41 weeks, 41.4, 41.5 weeks and 41.6 weeks with resolving of the pregnancy prior to 42.1 weeks.
5. If the client does not go into spontaneous labor the midwife may suggest the labor enhancement methods explained in the procedures below.
6. If the client does not go into spontaneous labor by 42 weeks the physician must be consulted. If the physician feels that the pregnancy can safely continue and the midwife concurs, the midwife will document and follow the physician’s guidelines for post term care.
PROCEDURE: 1. At each of the client visits following her EDD the following procedures will be followed:
· Complete all procedures normally followed in a prenatal exam including weight, blood pressure, fundal height measurement, urine dipstick, etc.
· Reassure the client that going post dates is normal and that her fetus is not at risk when all testing is within normal limits. Inform the client that two weeks post EDD is just as safe as at the due date as has been shown in numerous well documented medical studies.
· Inform the client of the definition and risks of post maturity and the extra visits and testing that we will perform to ascertain the health of her fetus and signs of post maturity.
· Determine the emotional status of the mother and her ability to wait for spontaneous labor. Discuss with her the methods of encouraging labor (listed below) and the protocol for “eviction” or labor enhancement (listed below).
· Remind the mother of the need for extra rest, extra fluids, nutrition and emotional care.
· Remind the mother of the protocol for fetal kick counting and encourage daily fetal movement counting with records to be brought to visits.
· An NST and AFI will be performed at each visit. If the NST is not reactive the physician will be informed and transfer will be planned. If the AFI is below 6 the mother will be informed to hydrate and arrive for retesting within 12 hours. If the AFI is still below 6 the physician will be informed and transfer will be planned.
2. The following procedures can be performed by the mother at home to encourage labor:
· Physical exercise/Walking
· Cotius (if no ROM) to encourage orgasm as an added benefit
· Nipple stimulation not to exceed 20 minutes at a time or 1 hour a day – to avoid nipple soreness and inability to breastfeed at birth
· Squatting/birth ball sitting
· 5 day herbal/homeopathic labor enhancement protocol
· Remind the mother to receive extra rest, fluids, and emotional care.
3. The following procedures can be contemplated for labor enhancement, assure that the mother is well rested, nourished and hydrated before attempting any of these protocols:
· A birth center series of 3 visits 1 hour apart for vigorous membrane sweeping.
· Black and Blue Cohosh mixture in tincture form to be given to mother orally, one dropperfull q 30 minutes for 4 hours maximum.
· Nipple stimulation (by hand or by breast pump) for 20 minutes, rest for 20 minutes, then repeat. This is to continue for no longer than 3 hours.
· Brisk walking for 30 to 45 minutes between other forms of encouragement.
· Homeopathic pulsitilla, 4-6, to be dissolved in 1 oz of water at to be given one spoonful by mouth q 15 minutes for 3 hours maximum
· All the above can be offered simultaneously.
4. The client’s chart will be reviewed as to which hospital she would be transferred to if she does not continue into spontaneous labor. If the client reaches 42 weeks the midwife will contact, by phone, the on call physician at the appropriate hospital and let the attending know the following information:
· The client’s history including:
o EDD/weeks of gestation
o Gravida and parity
o GBS status
o blood type and Rh
o results of most recent testing including Vital signs, NST and AFI
o Any additional pertinent information
· A transfer form will be filled out, transfer sheet will be given to the client with a copy of her records
· Client will be asked if she desires the midwife/doula to accompany her – she will be reminded that if we attend her in labor there will be no refund of the birth attendant funds (birth center or home birth charges will be refunded)
5. The Birth Center Clinical Director will be informed, by phone, prior to transfer of any post dates client.