Partus Immaturus,

Prematurus,
Serotinus.
Dr. Firmansyah, SpOG
Bagian Obgin / RSUD Raden Mattaher
FK-UNJA

Pengertian Persalinan:
Partus adalah suatu
proses persalinan hasil
konsepsi yang dapat
hidup dari dalam uterus
melalui vagina ke dunia
luar.

Partus immaturus
adalah suatu partus dari hasil konsepsi
yang dapat hidup tetapi belum a term
(cukup bulan).
- usia kehamilan antara 20 minggu
sampai < 28 minggu,
- berat janin antara 500-1000 gram.

Partus serotinus
(postmaturus)
adalah partus yang terjadi 2 minggu
atau lebih dari waktu partus yang
diperkirakan (taksiran persalinan).

Partus prematurus
adalah suatu partus dari hasil konsepsi
yang dapat hidup tetapi belum a term
(cukup bulan).
- usia kehamilan antara 28-36 minggu
- berat janin antara 1000-2500 gram.

Preterm labor is the presence of

contractions of sufficient strength
and frequency to effect
progressive effacement and
dilation of the cervix between
20 and 37 weeks' gestation.
WHO

Incidence : 6- 10%
Spontaneous

: 40-50%

PROM

: 25-40%

Obstetrically indicated : 20-25%

Most mortality and

morbidity is
experienced by babies
born before 34 weeks.

 Death
Respiratory distress syndrome
Hypothermia
Hypoglycaemia
Necrotising enterocolitis
Jaundice
Infection
Retinopathy of prematurity
Goldenberg, Obstetrics & Gynecology 11-2002

Three criteria to document PTL (20-37w)

1- Regular uterine contractions occur
at 4/20 min. or 8/60 min.
Plus: progressive change in the cervix.
2- Cervical dilatation > 1 cm.
3- Effacement > 80%.
American Academy of Pediatrician & ACOG 1997

Inhibition of labor
Corticosteroid
Antibiotics
Others.

 Bed rest
Hydration & sedation
Tocolytics

Until effective strategies are found, efforts

should be aimed at preventing newborn
complications by:
Corticosteroids
Antibiotics against group B strep
Avoiding traumatic deliveries.
Delivery in a center with experienced
resuscitation teams and neonatal
intensive care
ACOG NEWS RELEASE: November 2002

 Intravenous hydration does not seem

to be beneficial, even during the
period of evaluation soon after
admission,
Women with evidence of dehydration
may, however, benefit from the
intervention.
Stan et al (Cochrane Review 2000). In:
The Cochrane Library, Issue 1 2003. Oxford

 It is reasonable not to use tocolytic

drugs, as there is no clear evidence
that they improve outcome. However,
tocolysis should be considered if the
few days gained would be put to good
use, such as completing a course of
corticosteroids, or in utero transfer.
RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Most authorities do not

recommend use of tocolytics
at or after 34 weeks' .
There is no consensus on a
lower gestational age limit for
the use of tocolytic agents.
Goldenberg , Obstetrics &Gynecology 11-2002

B-Sympathomimetic
(Ritodrine)
Magnesium sulphate (MgSO4)
Indomethacin

Nifedipine = Epilate
Atosiban= Tractocile

Use of beta-agonists should

be restricted to the
management of preterm
labour between 20 and 35
completed weeks, including
women with ruptured
membranes. (Grade A)
RCOG Guideline Grade A recommendation 1997

There is insufficient evidence for any

firm conclusions about whether or not
maintenance tocolytic therapy following
threatened preterm labor is worthwhile.
Therefore maintenance therapy cannot
be recommended for routine practice.

RCOG Guideline Grade A recommendation 2002 (Valid:2005)

Antenatal corticosteroids are associated

with a significant reduction in rates of RDS,
neonatal death and intraventricular
haemorrhage, although the numbers
needed to treat increase significantly after
34 weeks' gestation.

RCOG Guidelines : Grade A Recommendation

The optimal treatment-delivery interval

for administration of antenatal
corticosteroids is after 24 hours but <
7 days after the start of treatment.

RCOG Guidelines : Grade A Recommendation

Two 12 mg doses of betamethasone

given IM 24 hours apart, Or
Four 6 mg doses of dexamethasone
given IM 12 hours apart (I-A).
There is no proof of efficacy for any
other regimen.
SOGC Recommendation Jan. 2003

There is no evidence of clear

overall benefit from
prophylactic antibiotics for
preterm labour with intact
membranes on neonatal
outcomes.
King & Flenady (Cochrane Review August 2002). In: The
Cochrane Library, Issue 1 2003. Oxford: Update Software.

ACOG Advises
Screening All
Pregnant Women
for Group B Strep.
ACOG NEWS RELEASE November 2002

All patients in preterm labor

are considered at high risk for
neonatal GBS sepsis and
should receive prophylactic
antibiotics regardless of
culture status.
Goldenberg , Obstetrics &Gynecology 11-2002

The goal of this strategy

is to prevent neonatal
sepsis, and not to prevent
preterm birth.
Goldenberg , Obstetrics &Gynecology 11-2002

Have not been shown to

significantly prevent
periventricular haemorrhages
in preterm infants.
Crowther & Henderson-Smart (Cochrane Review Novemb. 2000 ) In:The
Cochrane Library, Issue 1 2003. Oxford: Update Software
Crowther & Henderson-Smart (Cochrane Review May 2003 ) In:The
Cochrane Library, Issue 1 2003. Oxford: Update Software

Goldenberg, May 2003

Various strategies that have

been used to prevent or treat
preterm labor, haven't proven
effective.
Tocolysis should be considered
only for 2 days- if needed - for
corticosteroids thereby , or in
utero transfer to a tertiary center.

If a tocolytic drug is
used, ritodrine no
longer seems the best
choice.

Other drugs with fewer adverse effects

and comparable effectiveness are now
recommended.
Atosiban or nifedipine have been
recommended by RCOG.
Indomethacin may be used as a 2nd line
tocolytic or if there is polyhydramnous .

Maintenance tocolytic therapy

has no proven effect.
It cannot be recommended for
routine practice.

Postterm
Pregnancy

The term postterm, prolonged, postdates, and postmature are

often loosely used interchangeably to signify pregnancies that
have exceeded a duration considered to be the upper limit of
normal.

Postmature should be used to described the infant with

recognizable clinical features indicating a pathologically
prolonged pregnancy.

Postdates probably should be abandoned, because the real

issue in many postterm pregnancies is post-what dates?

Therefore, postterm or prolonged pregnancy is preferred

expression for an extended pregnancy.

The standard of definition of prolonged pregnancy:

42 completed weeks (294 days) or more from the first day of the
last menstrual periode.

Perinatal mortality

Perinatal mortality rate (stillbirths

plus early neonatal deaths)
At greater than 42 weeks of gestation
is twice that at term.
4-7 deaths versus 2-3 deaths per
1.000 deliveries.
Increases 6-fold and higher at 43
weeks of gestation and beyond.

Pathophysiology

The major causes of increased perinatal

mortality (Lucas and co-workers ,1965)
Pregnancy hypertension
Prolonged labor with cephalopelvic
disproportion
Intrapartum asphyxia
Meconium aspiration syndrome
Shoulder dystocia and macrosomia
Unexplained anoxia
Malformation
( i.e., anencephaly, adrenal hypoplasia )

Pathophysiology

Postmaturity syndrome

Postmature infants unique

& characteristic
appearances by
pathologically prolonged
pregnancy

Wrinked, patchy, peeling

skin on the palms and
soles
Long, thin body suggesting
wasting
Long nails
Open-eyed, unusually alert,
old & worried-looking face

Incidence: 10% of
pregnancies
between 41 and 43 weeks

Pathophysiology

Placental dysfunction

Clifford (1954)
Proposed the skin change of postmaturity were due to loss
of the protective effects of vernix caseosa

Stage of postmaturity

Stage I : clear AF
Stage II : skin was stained green
Stage III : skin discoloration yellow green

Attributed the postmaturity syndrome to placental

senescence, although did not find placental degeneration
histologically.

Pathophysiology

Placental dysfunction

Jazayeri and co-workers (1998)

Investigated cord erythropoietin levels in 124 appropriately grown

newborns delivered from 37 to 43 weeks

To assess whether fetal oxygenation was compromised due to

placental aging in postterm pregnancies

Decreased partial oxygen pressure is the only known stimulator of

erythropoietin

Cord erythropoietin levels significantly increased in pregnancies

reaching 41 weeks or more

Pathophysiology

Placental dysfunction
The postterm fetus may continue to gain weight,
and thus be an unusually large infant at birth.
This at least suggests that placental function is
not compromised.
Indeed, continued fetal growth, although at a
slower rate, is characteristic between 38 and 42
weeks.

Pathophysiology

Fetal distress and

oligohydramnios
Leveno and associates (1984)

Antepartum fetal jeopardy & intrapartum fetal distress

consequence of cord compression associated with
oligohydramnios

In their analysis of 727 postterm pregnancies, intrapartum fetal

distress detected with electronic monitoring was not associated with
late decelerations characteristic of uteroplacental insufficiency

One or more prolonged decelerations proceeded three fourths of

emergency cesarean deliveries for fetal jeopardy

In all but two cases, there were also variable decelerations

Another common fetal heart rate pattern was the saltatory baseline

Pathophysiology

Fetal distress and

oligohydramnios

Decreased amnionic fluid volume commonly develops as

pregnancy advances beyond 42 weeks

Meconium release into an already reduced amnionic fluid

volume
causes thick, viscous meconium
implicated in meconium aspiration syndrome

Pathophysiology

Fetal growth restriction

Divon and co-authors (1998) and Clausson and co-workers

(1999) analyzed births of almost 700.000 women between 1991
and 1995 using the National Swedish Medical Birth registry

Stillbirths were more common among growth-restricted infants

who were delivered at 42 weeks or beyond

Indeed, one third of the postterm stillbirths were growth restricted

Management

Major issue

(Postterm Pregnancy)

Whether to intervene at 41 or 42 weeks.

Whether labor induction is warranted compared with expectant

management using antepartum fetal testing.

Roussis and colleague (1993)

Two thirds of respondents induced labor at 41 weeks

if the cervix was favorable.
Antepartum fetal testing was advocated beginning at 41weeks
when the cervix was unfavorable.

Management

Unfavorable cervix
It is difficult to precisely define in prolonged pregnancies

Harris and colleagues (1983)

Hannah and colleagues (1992)

Undilated cervix.

Alexander and associates (2000)

A Bishop score of less than 7.

Women in whom there was no cervical dilatation had a two-fold

increased cesarean delivery rate for dystocia.

Yang and co-worker (2004)

Cervical length of 3 cm or less predictive successful induction.

Management

Unfavorable cervix

Prostaglandin E2

Sweeping of stripping of the membranes

The American college of obstetrician and Gynecologists (1997)

Prostaglandin gel can be safely in postterm pregnancy
Use of PG for cervical ripening is discussed

Boulvain and co-authors (1999)

At 38 to 40 weeks decreased the frequency of postterm pregnancy
Not modify the risk for cesarean delivery

Station of the vertex

The cesarean delivery rate directly related to station

6% if the vertex was -1, 20% at -2, 43% at -3, and 77% at-4

Bishop score
SKOR
Pembukaan serviks (cm)
Pendataran serviks
Penurunan kepala (station)
Konsistensi serviks
Posisi serviks

1-2

3-4

5-6

0-30%

40-50%

60-70%

80%

-3

-2

-1/0

+1/+2

keras

sedang

lunak

posterior

medial

anterior

Management

Induction versus fetal testing

Hannah and colleagues (1992)

Menticoglou and Hall (2002)

Labor induction resulted in a significantly lower cesarean rate (21%)

compared with pregnancies managed with antepartum testing (24%)

Lamented that induction of labor at 41 weeks has become standard

of care in Canada
Because it caused interference that had the potential to do more
harm than good & have staggering resource implications

Alexander and colleagues (2001, at Parkland Hospital)

Rates of cesarean delivery significantly increased in the induced

group because of failure to progress compared with spontaneous
labor (19 versus 14%).
Risk factors: nulliparity, unfavorable cervix & epidural analgesia.

Management

Induction versus fetal testing

Evidence to substantiate intervention-whether induction or fetal

testing-commencing at 41 versus 42 weeks is limited

Usher and colleagues (1988)

Perinatal death rates, corrected for malformations

1.5, 0.7, and 3.0 per 1000 for 40, 41, and 42 weeks

Based on results summarized in Table 37-1, 41-week pregnancies

without other complications considered normal pregnancies at
Parkland Hospital.

Management

Oligohydramnios

When amnionic fluid is decreased in a postterm pregnancyor for that matter in any pregnancy- the fetus is at increased
risk.

The smaller the amnionic fluid pocket, the greater the

likelihood that there was clinically significant
oligohydramnios.

Amnionic fluid index (AFI) overestimated the number of

abnormal outcomes in postterm pregnancies .

Regardless of the criteria used to diagnosis oligohydramnios

increased incidence of fetal distress during labor.

Management

Macrosomia

Incidence of macrosomia (defined as birthweight greater than

4500 g) increases from 1.4 % at 37 to 41 weeks to 2.2 %
at 42 weeks or more (Marin and colleagues, 2002)

Current evidence doesnt support a policy of early labor induction

in women at term who have suspected fetal macrosomia.

Cesarean delivery recommended for estimated fetal weights

greater than 4500 g in the presence of a prolonged secondstage labor or a second-stage arrest of descent

Management

Recommendations of the ACOG

(the American College of Obstetricians and
Gynecologists)

Although providing flexibility in the evaluation & management of

pregnancies completing 42 weeks
Antenatal testing or labor induction should be commenced

Postterm pregnancy has been identified as high-risk condition

twice-weekly antepartum fetal testing may be indicated

Oligohydramnios defined as no vertical pocket of amnionic fluid

greater than 2 cm or an AFI of 5 cm or less
indication for either delivery or close fetal suveillance

Management

Postterm Pregnancy

Management

Postterm Pregnancy

Management at Parkland Hospital

In women with a certain gestational age, labor is induced at the

completion of 42 weeks

90% of such women are induced successfully

For those who do not deliver with the first induction

a second induction is performed within 3 days

If not delivered, management decisions involve

a third (or more) induction versus cesarean delivery

Management

Postterm Pregnancy

Management at Parkland Hospital

Women classified having uncertain postterm pregnancies are

followed on a weekly basis & without intervention unless fetal
jeopardy is suspected

Decreased amnionic fluid volume & diminished fetal movement

Labor induction as described previously for the woman with
a certain postterm gestation

Management

Postterm Pregnancy

Medical or Obstetrical Complications

In the event of a medical or obstetrical complications

unwise to allow a pregnancy to continue past 42 weeks

In many such instances early delivery is indicated

Common examples

Hypertensive disorders due to pregnancy

Prior cesarean delivery
Diabetes

Management

Postterm Pregnancy

Intrapartum Management

While being observed for possible labor continuous

electronic monitoring for variations consistent with fetal
distress
(American College of Obstetricians and Gynecologists, 1995)

Amniotomy

Reduction in fluid volume the possibility of cord compression

Diagnosis of thick meconium to be dangerous to the fetus if
aspirated
Scalp electrode and intrauterine pressure catheter can be placed

Management

Postterm Pregnancy

Intrapartum Management

The viscosity of thick meconium

Signifies the lack of liquid & oligohydramnios

Aspiration of thick meconium
severe pulmonary dysfunction & neonatal death
Amnioinfusion during labor as a way of diluting meconium to decrease
the incidence of meconium aspiration syndrome.

Management

Postterm Pregnancy

Intrapartum Management

The viscosity of thick meconium

The likelihood of a successful vaginal delivery is reduced

appreciably for the nulliparous woman who is in early labor with
thick, meconium-stained amnionic fluid
When the woman remote from delivery prompt cesarean delivery,
especially when cephalopelvic disproportion is suspected or either
hypertonic or hypertonic dysfunctional labor is evident

Management

Postterm Pregnancy

Intrapartum Management

Aspiration of meconium

Suction of the pharynx as soon as the head is delivered

If meconium is identified , the trachea should be aspirated
as soon as possible after delivery
The infant should ventilated as needed

Thank You