PROLONGED LABOUR

BY: Savita ahlawat

M.Sc NurSiNg

NOrMal laBOur

- Presence of regular painful uterine contractions becoming progressively stronger and more frequent accompanied by effacement and progressive dilatation of the cervix and decent of the presenting part. - At its onset its usually accompanied by bloody mucoid vaginal discharge called show. - The process culminates in expulsion of the baby and other products of conception.

FirSt StagE OF laBOur

DEFiNitiON PrOlONgED laBOur

-Combined duration of the first and second stage is more than the arbitrary time limit of 18 hours to 24 hours. In a multiparous - exceeds 12 hrs.-The prolongation may be due to protracted cervical dilatation in the first stage and/or inadequate descent of the presenting part during the first or second stage of labor.-Cervical dilatation rate is less than 1 cm/hr -Descent of the presenting part is < 1 cm/hr for a period of minimum 4 hours.

cauSES OF PrOlONgED laBOr:

FIRST STAGE: Failure to dilate the cervix is due to—

• Fault in power: Abnormal uterine contraction such as uterine inertia (common) or inco-ordinate uterine contraction

Fault in the passenger: • Malposition (OP) and malpresentation

(face, brow)• Congenital anomalies of the fetus

(hydrocephalus). • Too often deflexed head• Minor degrees of pelvic contraction

• Disordered uterine action have got sinister effects in causing non-dilatation of the cervix.

Others: • Injudicious (early) administration of

sedatives and analgesics before the active labor begins.

SEcOND StagEFault in the power: • Uterine inertia • Inability to bear down • Epidural analgesia • Constriction ring.Fault in the passage: • Cephalopelvic disproportion, android

pelvis, contracted pelvis • Undue resistance of the pelvic floor or

perineum due to spasm or old scarring • Soft tissue pelvic tumor.

Fault in the passenger:

• Malposition (occipito-posterior)

• Malpresentation

• Big baby

• Congenital malformation of the baby.

SigN aND SYMPtOMS OF PrOlONgED laBOur

DIAGNOSIS: • Abdominal And Vaginal Examination.

• During vaginal examination, if a finger is accommodated in between the cervix and the head during uterine contraction pelvic adequacy can be reasonably established.

• Intranatal imaging (radiography, CT or MRI) is of help in determining the fetal station and position as well as pelvic shape and size.

FIRST STAGE • The duration is more

than 12 hours. • The rate of cervical

dilatation is < 1 cm/hr in a primi and <1.5 cm/hr in a multi.

• The rate of descent of the presenting part is < 1 cm/hr in a primi and < 2 cm/hr in a multi.

• In a partograph (WHO-1994) the labor process is divided into

• Latent phase that ends when the cervix is 3 cm dilated.

• Active phase—Starts with cervical dilatation of 3 cm or more.

• Cervix should dilate at least 1 cm/hr in this active phase. Cervical dilatation rate (cervicograph) is plotted in relation to alert line and action line.

• Alert line starts at the end of latent phase (3 cm cervical dilatation) and ends with full dilatation of the cervix (10 cm) in 7 hours (1 cm/hr dilatation rate).

• The action line is drawn 4 hours to the right of the alert line. An interval of 4 hours is allowed to diagnose delay in active phase and then appropriate intervention is done. Labor is considered abnormal when cervicograph crosses the alert line and falls on zone 2 and intervention is required when it crosses the action line and falls on zone 3

PROLONGED LATENT PHASE

• Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labor. Mean duration of latent phase is about 8 hours in a primi and 4 hours in a multi.

• A latent phase that exceeds 20 hours in primigravidae or 14 hours in multiparae is abnormal.

•

CAUSES

. Unripe Cervix at the onset of labour

• Malposition And Malpresentation • Cephalopelvic Disproportion• Premature Rupture of the membranes.

MANAGEMENT• Rest and analgesic are usually

given. When augmentation is decided, medical methods (oxytocin or prostaglandins) are preferred.

• Amniotomy is usually avoided.

• Prolonged latent phase is not an indication for cesarean delivery.

DISORDERS OF THE ACTIVE PHASE

• Active phase disorders may be divided into:

• (A) Protraction

• (B) Arrest disorders.

•

PROTRACTED ACTIVE PHASE OR PRImARy DySFunCTIOnAl

lAbOuR:• When the rate of cervical dilatation is <

1.2 cm/hr in a primipara and < 1.5 cm/hr in a multipara.

• A protracted active phase may be due to—

• Inadequate uterine contractions • Cephalopelvic disproportion • Malposition (OP) or malpresentation

(brow) or • Epidual anesthesia.

ARREST DISORDER:• Arrest of dilatation is defined when no cervical

dilatation occurs after 2 hours in the active phase of labor.

• It is commonly due to inefficient uterine contractions.

• No descent for a period of > 1 hour is called arrest of descent. It is commonly due to CPD.

• Secondary arrest is defined when the active phase of labor (cervical dilatation) commences normally but stops or slows significantly for 2 hours or more prior to full dilatation of the cervix. It is commonly due to malposition or CPD.

SECOnD STAGE

• Mean duration of second stage is 50 minutes for nullipara and 20 minutes in multipara.

• Prolonged second stage is diagnosed if the duration exceeds 2 hours in nullipara and 1 hour in a multipara when no regional anesthesia is used.

•

DISORDERS OF THE SECOnD STAGE

• Protraction of descent is defined when the descent of the presenting part is at < 1 cm/hr in a nullipara or < 2 cm/hr in a multipara.

• Arrest of descent is diagnosed when no progress in descent is observed. It may be due to one or a combination of several underlying abnormalities like CPD, malposition (OP), malpresentation, inadequate uterine contradictions or asynclitism.

DAnGERS: (A) FETAL:

• Hypoxia due to diminished uteroplacental circulation specially after rupture of the membranes.

• Intrauterine infection

• Intracranial stress or hemorrhage following prolonged stay in the perineum and/or supermoulding of the head

• Increased operative delivery.

mATERnAl:• (1) Distress • (2) Postpartum hemorrhage • (3) Trauma to the genital tract—

concealed (undue stretching of the perineal muscles which may be the cause of prolapsed at a later period) or revealed such as cervical tear, rupture uterus

• (4) Increased operative delivery • (5) Puerperal sepsis • (6) Subinvolution.

TREATmEnT AnD PREVEnTIOn

– Antenatal or early intranatal detection of the factors likely to produce prolonged labor (big baby, small women, malpresentation or position).

– Use of partograph helps early detection.– Selective and judicious augmentation of

labor by low rupture of the membranes followed by oxytocin Drip.

– Change of posture in labor other than supine to increase uterine contractions, avoidance of dehydration in labor and use of adequate analgesia for pain relief.

PATTERN DIAGNOSTICCRITERIA

Prolonged Latent phase

Nulliparousmultiparous

20 hours or more14 hrs or more

Primary dysfunctional labour(protractional disorder)

NulliparousMultiparous

<1.2 cm/hr<1.5 cm/hr

Prolonged deceleration phase(7-10 cm dilation)

NulliparousMultiparous

3 hrs or more1 hr or more

Secondary arrest of dilation

Arrest 2 hrs or more

Protracted descent NulliparousMultiparous

<1 cm/hr<2 cm/hr

Arrest of descent Arrest 1 hour or more

Prolonged 2nd stage No descent in the 2nd stage

ACTUAL TREATMENT:

• Careful evaluation is to be done to find out—Cause of

prolonged laborEffect on the

mother Effect on the fetus.

DEFINITIVE TREATMENT:

• First stage delay—• Vaginal examination is done to verify the fetal

presentation, position and station. – Clinical pelvimetry is done. – If only uterine activity is suboptimal, Amniotomy and/

or oxytocin infusion is adequate. – Effective pain relief is given by intramuscular

pethidine or by regional (epidural) analgesia. For the management of secondary arrest specially in multipara one should be very careful to use oxytocin.

– Cesarean section is done when vaginal delivery is unsafe (malpresentation, malposition, big baby, or CPD).

•

SECOND STAGE DELAY

• Short period of expectant management is reasonable provided the FHR (electronic monitoring) is reassuring and vaginal delivery is imminent. Otherwise appropriate assisted delivery, vaginal (forceps, ventouse) or abdominal (cesarean) should be done. Difficult instrumental delivery should be avoided.

PHARMACOLOGICAL TREATMENT

• Adequate analgesia should be offered to the mother such as IM pethidine 75mg before dilation of os 5cm as prescribed.

• Where labour is prolonged an epidural block may be given.

NURSING MANAGEMENT

Assessment of progress in prolonged labour

FETAL WELL BEING

• Monitor CTG to determine fetal distress

• Preparation are made for either a CS if the first stage of labour is prolonged, or for an instrumental delivery or Cs in the second stage of labour.