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Prolonged labour

1. SUBJECT: MIDWIFERY AND OBSTETRICAL NURSING TOPIC : PROLONGED LABOR SUBMITTED TO, SUBMITTED BY MS BIJLEE MANI MS VEENA SUDARSANAN ASST PROFESSOR 1V th YEAR BSc (N) DEPT OF OBG REG NO:15NO399 SDMIONS SDMIONS SDM INSTITUTE OF NURSING SCIENCE

2. Prolonged labor or a failure to progress is the inability of a woman to proceed with child birth upon going into labor. Prolonged labor typically lasts over 20 hours for the primi mothers and over 14 hours for multi parae mothers. Prolonged labor is determined based on information that is being collected regarding the strength and time between contraction. Prolonged labor in the developing world is commonly due to cephalo pelvic disproportion. INTRODUCTION

3. The labor is said to be prolonged when the combined duration of the first stage and second stage is more than the arbitrary time limit of 18 hours. DEFINITION

4. Prolonged labor may be due to;- Protracted cervical dilatation in first stage or inadequate descent of the presenting part during first or second stage of labor. Cervical dilatation less than 1cm/h Descent of the presenting part is less than 1cm/h for a period of minimum 4 hours observation. Inefficient uterine contraction .

5. Latent phase is the preparatory phase of the uterus and the cervix before the actual onset of labor. The mean duration of latent phase:- 8hrs in primi gravidae and 12hrs in m ultiparae A latent phase that exceeds:- 20hrs in p rimi gravidae and 14hrs in multiparae . PROLONGED LATENT PHASE

6. Unripe cervix Malposition and malpresentation Cephalopelvic disproportion Premature rupture of the membranes Induction of labor Early onset of regional anesthetic CAUSES

7. First Stage:- Failure to dilate the cervix is due to, Fault in power: Abnormal uterine contraction such as uterine inertia(common) or incoordinate uterine contraction. Fault in passage: Contracted pelvis, Pelvic tumor, Cervical dystocia . Fault in passenger: Malposition and malpresentation , congenital anomalies of the fetus. Others: Early administration of sedatives and analgesics.

8. Second Stage:- Sluggish or non descent of the presenting part in the second stage is due to; Fault in power: Uterine inertia Inability to bear down Regional (Epidural) analgesia Constriction ring.

9. Fault in passage: Cephalopelvic disproportion, android pelvis, contracted pelvis Undue resistance of the pelvic floor Soft tissue pelvic tumor Fault in passenger: Malposition Malpresentation Big baby Congenital malformation of the baby

10. (A)First Stage: First stage of labor is considered prolonged when the duration is more than 12 hours. Cervical dilatation is <1cm/h in primi and <1.5cm/h in a multi. The rate of the descent of the presenting part is <1cm/h in a primi and <2cm/h in a multi.

11. In a partograph the labor process is divided into; Latent phase Active phase

12. Cervical dilatation rate is plotted in relation to alert line and action line: Alert line:- Starts at the end of latent phase and ends with full dilatation of the cervix in 6hours. Action line:- The action line is drawn 4hours to the right of alert line. A interval 4hours is allowed to diagnose delay in active phase.

13. Protraction Arrest disorders Protracted Active Phase The rate of cervical dilatation is <1.2cm/h in a primipara and <1.5cm/h in multipara . DISORDERS OF ACTIVE PHASE:-

14. A protracted active phase may be due to;- Inadequate uterine contractions Cephalopelvic disproportion Malposition or Malpresentation Regional anaesthesia

15. Secondary Arrest The active phase of labor commences normally but stops or slows significantly for 2hours or more prior to full dilatation of the cervix.

16. (B) Second Stage: Mean duration of second stage is 50minutes for nullipara and 20minutes in multipara . Prolonged second stage if duration exceeds 2hours in nullipara and 1hours in multipara .

17. Protraction of the descent : Is defined when the descent of presenting part is at <1cm/h in nullipara or <2cm/h in multipara . Arrest of descent: No progress in descent is observed over a period of atleast 2hours. DISORDERS OF SECOND STAGE:-

18. The fetal risk is increased due to the combined effects of: Hypoxia Intra uterine infection, Pneumonia Intra cranial stress or Hemorrhage Increased operative delivery DANGERS: FETUS

19. Distress Chorioamnionitis PPH Trauma to the genital tract Increased operative delivery Puerperal sepsis Subinvolution DANGERS: MATERNAL

20. Vaginal examination Intra natal imaging DIAGNOSIS

21. Complete rest Analgesics Medical method are preferred Amniotomy is usually avoided MANAGEMENT

22. Prevention Antenatal or early intranatal detection Use of partograph Selective and judicious augmentation Change of posture in labor Actual Treatment Careful evaluation is to be done to find out;- Cause of prolonged labor, effect on the mother, effect on the fetus TREATMENT

23. In nulliparous patient inadequate uterine activity In multiparous patient cephalopelvic disproportion Definitive Treatment First stage Delay- Vaginal examination, Clinical Pelvimetry , Oxytocin infusion, Analgesic Second Stage Delay- Vaginal ( forceps,ventouse ) or cesarean