Intrapartum management

1. Meconium staining is more common in postdates pregnancies. If oligohydramnios is present, amnioinfusion dilutes meconium and decreases the number of infants with meconium below the vocal cords. Instillation of normal saline through an intrauterine pressure catheter may reduce variable decelerations.

2. Macrosomia should be suspected in all postdates gestations. Fetal weight should be estimated prior to labor in all postdates pregnancies. Ultrasonographic weight predictions generally fall within 20% of the actual birth weight.

3. Management of suspected macrosomia. The pediatrician and anesthesiologist should be notified so that they can prepare for delivery. Cesarean delivery should be considered in patients with an estimated fetal weight greater than 4500 g and a marginal pelvis, or someone with a previous difficult vaginal delivery with a similarly sized or larger infant.

4. Intrapartum asphyxia is also more common in the postdates pregnancy. Therefore, close observation of the fetal heart rate tracing is necessary during labor. Variable decelerations representing cord compression are frequently seen in postdates pregnancies

5. Cord compression can be treated with amnioinfusion, which can reduce variable decelerations. Late decelerations are more direct evidence of fetal hypoxia. If intermittent, late decelerations are managed conservatively with positioning and oxygen. If persistent late decelerations are associated with decreased variability or an elevated baseline fetal heart rate, immediate evaluation or delivery is indicated. This additional evaluation can include observation for fetal heart acceleration following fetal scalp or acoustic stimulation, or a fetal scalp pH.

References: See page 184.

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