Prolonged labour

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children.

1. MRs : Babitha Mathew MSc OBG Assistant professor CON, NMC, Muvattupuzha

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 hours .”

3. 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. Labour is considered prolonged when the cervical dilatation rate is less than 1 cm/ hr and descent of the presenting part is < 1 cm/ hr for a period of minimum 4 hours observation ( WHO- 1994 )

4. Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labour. 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 PROLONGED LATENT PHASE

5. The causes include:- 1) Unriped Cervix 2) Malposition and Malpresentation 3) Cephalopelvic Disproportion 4) Premature Rupture of the Membranes Prolonged latent phase may be worrisome to the patient but does not endanger the mother or fetus.

6. Expectant management is usually done unless there is any indication (for the or mother) for expediting the delivery . 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 section delivery . PROLONGED LATENT PHASE MANAGEMENT

7. CAUSES OF PROLONGED LABOUR FIRST STAGE FAULT IN POWER FAULT IN PASSAGE FAULT IN PASSENGER

8. Failure to dilate the cervix is due to:- FAULT IN POWER Abnormal Uterine Contraction such as uterine inertia or incoordinate uterine contraction FAULT IN PASSAGE Contracted pelvis, cervical Dystocia, Pelvic Tumor , or even full bladder FAULT IN PASSENGER Malposition (OP) and Malpresentation (face , brow), congenital anomalies of the fetus (hydrocephalus ) Too often deflexed head, minor degrees of pelvic contraction and disordered uterine action have got sinister (threatening) effect in causing non-dilatation of cervix . OTHERS Injudicious (early) administration of sedatives and analgesics before the active labour begins.

9. SECOND STAGE FAULT IN POWER FAULT IN PASSAGE FAULT IN PASSENGER

10. Sluggish or non-descent of the presenting part in the second stage is due to: 1) Fault in the power: Uterine inertia ( 2) Inability to bear down ( 3) Epidural analgesia ( 4) Constriction ring . 2)Fault in the passage: Cephalopelvic disproportion, android pelvis, contracted pelvis ( 2) Undue resistance of the pelvic floor or perineum due to spasm or old scarring ( 3) Soft tissue pelvic tumor . 3)Fault in the passenger: (1) Malposition ( occipito -posterior) (2) Malpresentation (3) Big baby (4) Congenital malformation of the baby.

11. Prolonged labour is not a diagnosis but it is the manifestation of an abnormality , the cause of which should be detected by a thorough abdominal and vaginal examination During vaginal examination if the finger is accomodated in between the cervix and the head during uterine contraction pelvic adequecy can be reason ably established . Intranatal imaging ( radiography, CT or MRI) is of help in determining the fetal station and position as well as pelvic shape and size. DIAGNOSIS

12. FIRST STAGE Duration is > 12 hours. The rate of Cervical dilatation rate < 1 cm/ hr in primi and < 1.5 cm/ hr in a multi Rate of descent of presenting part is < 1 cm/hr in primi and < 2cm/hr in multi DISORDERS OF ACTIVE PHASE A) Protracted (prolongated) active phase It may be due to:- Inadequate uterine contraction Cephalopelvic disproportion Malposition Malpresentation Epidural anaesthesia

13. B) Arrest Disorder When no dilatation occurs after 2 hours in active phase of labour Commonly due to:- Inefficient uterine contraction No descent for a period of > 1hour is called arrest of descent . It is commonly due to CPD Secondary Arrest When Active stage of labour commences normally but stops or slows significantly for 2 hours or more prior to full dilatation of the cervix Commonly due to malposition or CPD

14. SECOND STAGE Mean duration of second stage is 50 minutes for nullipara and 20 minutes for multipara Prolonged stage is diagnosed if the duration exceeds 2 hours in nullipara and 1 hour in a multipara when no regional anesthesia used. 1 hour or more is usually permitted in both the groups when regional anesthesia is used during labour.

15. (A ) Protraction Descent When :- Descent of presenting part is < 1 cm/ hr in nullipara and < 2 cm/hr in multipara (B) Arrest of descent 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 . DISORDERS OF SECOND STAGE

16. (1) Hypoxia due to diminished uteroplacental circulation specially after rupture of the membranes. (2) Intrauterine infection ( 3) Intracranial stress or hemorrhage following prolonged stay in the perineum and/or supermoulding of the head ( 4) Increased operative delivery DANGERS FETAL

17. Maternal :

18. PREVENTION:- Antenatal or early Intranatal detection Use of partograph Selective and injudicious augmentation Change of posture in labour, emotional support, avoidance of dehydration in labour and use of adequate analgesia for pain relief TREATMENT

19. ACTUAL MANAGEMENT Careful evaluation is to be done to find out :- Cause of prolonged labour Effect on the mother Effect on the fetus In nulliparous women: Inadequete uterine activity, primary dysfunctional labour In multiparous women: CPD,

20. PRELIMINERIES Correction of dehydration and ketoacidosis by IV fluids in case of neglacted prolonged labour DEFINITIVE TREATMENT FIRST STAGE DELAY IF only uterine activity is suboptimal, Amniotomy / oxytocin infusion Effective pain relief SECONDARY ARREST Careful use of oxytocin Cesarean section delivery

21. SECOND STAGE DELAY Short period of expectant management is reasonable provided the FHR is reassuaring and vaginal delivery is emminent Otherwise , appropriate assisted delivery , vaginal or abdominal should be done . Difficult instrumental delivery should be avoided.

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