Prolonged labour

Definition , Latent phase,prolonged latent phase , Causes, diagnosis first stage , second stage , treatment first stage ,second stage

1. PROLONGED LABOUR - DR. SUPRIYA MAHIND

2. DEFINITION The labour is said to be prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hrs

3. LATENT PHASE Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labour . Normal latent phase is about 8 hours in primi 4 hours in multi

4. PROLONGED LATENT PHASE A latent phase that exeeds 20 hours in primigravida or 14 hours in multigravida is abnormal

5. Partographic analysis of labor to detect types of prolonged labor—protracted latent phase, protracted active phase and secondary arrest.

6. Cervicograph showing slow (protracted) cervical dilatation and descent of the presenting part. Oxytocin infusion was started following amniotomy . Partograph showed arrest in the progress in spite of adequate contractions. Labor was terminated by cesarean section

7. In a partograph the labour process divided into Alert line Action line Latent phase : latent phase that end with the cervix is 3 cm dilated Active phase : starts with cervical dilatation of 3 cm cervix should dilate at least 1 Cm / hr

8. Alert line – start at the end of the latent phase and end with the full dilatation of cervix (10cm) in 7 hours . ( 1 cm / hr dilatation) Action line – its drawn four 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 . Labour is considered abnormal when cervicograph crosses alert line

9. CAUSES Unripe cervix Malposition and malpresentations Cephalopelvic disproportion Premature rupture of the membranes Abnormal uterine contractions Contracted pelvis Congenital malformations of the baby

10. CAUSES OF PROLONGED LABOUR First stage Failure to dilate the cervix is due to Fault in power – Abnormal uterine contraction such as Uterine inertia In co-ordinate uterus contraction Fault in passage - Contracted pelvis Cervical dystocia Pelvic tumor or even full bladder

11. Fault in passenger – Malposition and malpresentations Congenital anamolies of the fetus Others : Early administrations of sedatives Analgesics before active labour begins

12. SECOND STAGE Sluggish or non descent of the presenting part in 2 nd stage due to Fault in power Uterine inertia Inability to bear down Epidural analgesia Constriction ring

13. Fault in passage CPD Android pelvis Contracted pelvis Soft tissue Pelvic tumour Undue resistance to the pelvic floor

14. Fault in passenger Malposition and Malpresentations Big baby Congenital malformation of the baby

15. DIAGNOSIS It is not a diagnosis but it is the manifestation of an abnormality . FIRST STAGE First stage of labour is considered prolonged when the duration is more than 12 hrs . The rate of cervical dilatation is < 1 cm / hr in primi and < 1.5 cm / hr in multi . The rate of descent if the presenting part is < 1 cm / hr in primi and < 2 cm / hr in multi

16. SECOND STAGE The 2 nd stage is considered prolonged if it lasts for more than 2 hrs in primi , and 1 hr in multi. The diagnostic features are – Sluggish or non descent of the presenting part even after full dilatation of the cervix Variable degrees of moulding and caput formation in cephalic presentation Identification of the cause of prolongation

17. DANGERS FETAL The fetal risk is increased due to combined effects of Hypoxia Intrauterine infection Intracranial stress or hemorrhage Increased operative delivery

18. MATERNAL There is increased incidence of Distress Postpartum hemorrhage Trauma to genital track Increased operative delivery Puerperal sepsis Subinvolution

19. TREATMENT PREVENTION Antenatal or early intranatal detection of the factors likely to produce prolonged labour Use of partograph Selective and judicious augmentation of labour by low rupture of membranes followed by oxytocin drip.

20. Change of posture in labour other than supine to increase the uterine contractions Avoidance of labour dehydration Use of adequate analgesia for pain relief

21. Actual treatment Careful evaluation is done to find out Causes of prolonged labour Effect on the mother Effect on the fetus

22. PRELIMINARIES Correction of keto-acidosis should be done urgently by rapid intravenous infusion of Ringer’s solution .

23. 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 IM inj : Pethidine or by regional analgesia. Caeserian section is done when vaginal delivery is unsafe

24. second stage delay Short period of expectant management is reasonable provided the FHR is reassuring and vaginal delivery is imminent . Otherwise appropriate assisted vaginal delivery (forceps, ventose )

25. FORCEP DELIVERY

26. LSCS Should be done

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