PROLONGED LABOUR

General Objective: To Deliver Knowledge To The Students Regarding Prolonged Labour

LEARNING OBJECTIVES: At the end of the learning session, the student should be able to: 1. define prolonged labour 2. state the factors predisposing to prolonged labour 3. explain the clinical manifestation of prolonged labour 4. describe the management of mother with prolonged labour 5. state the possible outcome of prolonged labour 6. state the complications of prolonged labour

Definition of 1st stage

Latent phase is prior to active 1st stage of labour and may last 6-8hrs in first time mothers when the cervix dilates from 0cm to 3-4cm dilated (Stables 1999) and the cervical canal shorterns from 3cm long to <0.5cn long (Arulkumaran 1996). The active 1st stage is the time when the cervix undergoes more rapid dilatation. This begin when the cervix is 3-4cm dilated and the presence of rhythmic contractions is complete when the cervix is fully dilated (10cm).
459 Myles adition 15 page

Definition of 2nd stage

The 2nd stage is that of expultion of the fetus. It begins when the cervix is fully dilated in physiological labour the women usually feels the urge to expel the fetus. It is complete where the baby is born.

Myles adition 15 page 459

Definition 3rd stage

The 3rd stage is that of separation and expulsion of placenta and membranes. It also involves the control of bleeding. It last from the birth of the baby until the placenta and membranes have been expelled.

Myles adition

Definition normal labour

Labour is the process by which a viable foetus i.e. at the end of 28 weeks or more is expelled or is going to be expelled from the uterus. Delivery means actual birth of the foetus. The following criteria should be present to call it normal labour:

Spontaneous expulsion, of a single, mature foetus, presented by vertex, through the birth canal, within a reasonable time (not less than 3 hours or more than 18 hours), without complications to the mother, or the foetus.

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Definition precipitate labour

A labour is very fast lasting less than 2 hours, and in which the contractions are intense.
Illustrated dictionary of midwifery pg 178

the uterus is over-efficient and the onset of labour to birth is an hour or less. Much or of the 1st stage is not recognized because contractions are not painful and the realization of the birth of the head maybe the 1st indication that labour has

Definition obstructed labour

It is the arrest of vaginal delivery of the foetus due to mechanical obstruction.

Aetiology
Maternal
Bony

causes

obstruction: e.g.

Contracted pelvis. Tumours of pelvic bones.

Soft

tissue obstruction:

Uterus: impacted subserous pedunculated fibroid, constriction ring opposite the neck of the foetus. Cervix: cervical dystocia. Vagina: septa, stenosis, tumours.

Cont..

Foetal causes

Malpresentations and malpositions: e.g.

Persistent occipito-posterior and deep transverse arrest, Persistent mento-posterior and transverse arrest of the face presentation. Brow, Shoulder, Impacted frank breech.

Large sized foetus (macrosomia). Congenital anomalies: e.g.

Hydrocephalus. Foetal ascitis. Foetal tumours.

Locked and conjoined twins.

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Define prolonged labour

Prolonged labour is not easily defined primarily because there is no consensus as to what constitutes a normal time limit for labour either in the latent or active part of the 1st stage or the passive or active part of the 2nd stage. The WHO (1994) defines prolonged labour as one that exceeds 18hrs in primiparous women.
Myles text book edition 15 pg 565

FACTORS PREDISPOSING TO PROLONGED LABOUR: power passage Passanger

Common in primigravida.

POWER
1) Problems With Uterine Contraction The uterine muscle may fail to contract properly when it is grossly distended as in twin pregnancy and hydramnios (excess liquor amni). Presence of tumours like fibroids in the uterine musculature can also affect uterine contraction.

PASSAGE
1) CEPHALOPELVIS DISPROPORTION (CPD) CPD is said to occur when the size of the fetal head is bigger then the size of the maternal pelvic passage or birth canal. In most pregnant women in labor, ligaments and joints tend to become more flexible, enabling them to relax more at the time of labor.

2)Cervical dystocia or stenosis: The term cervical dystocia is used when the cervix fails to dilate properly and remains at the same position for more than 2 hours. The cervix may fail to dilate when it is fibrosed due to previous operations like cone biopsy or due to the presence of tumors like cervical polyps and fibroids.

Cont.

Any change in this position can cause prolongation in the duration in labor. A breech presentation in which the fetus is in the buttocks down position, a face presentation in which the fetus faces the mother's abdomen, or a deflexed position of the head in which the neck of the fetus is less flexed or even straight or extended can all cause prolonged labor.

PASSENGER
1)the baby is very big, as in a diabetic mother or a physically very smallbuilt mother, or if the mother has had a fractured pelvis. 2)Malpresentations: The normal position of the fetus is longitudinal with the fetal spine parallel to the mother's spine. The fetus lies in a completely flexed position with the chin touching the chest and the arms and legs flexed in front. The fetus normally faces the mother's back for a

Cont.
Use of Sedatives and Anesthesia: Excessive use of painkillers or anesthesia can cause inefficient uterine action. They can also decrease the pain of normal labour and prevent voluntary effort by the mother to deliver the baby during the second stage of labor

The Clinical Manifestasi Of Prolonged Labour

Duration of labour. Labor extends for more than 18 hours. Maternal condition Patient looks exhausted and distressed. Dehydration may be present. Mouth may be dry due to prolonged mouth breathing. Pain Pain may be more on the back radiating to the thighs rather than inside the abdomen. This is due to pressure over the muscles and ligaments. Labor pains may initially be severe, frequent and

Cont. Vital Signs Pulse rate is often high. Temperature Abdominal palpation Theuterusis tender on palpation and does not relax fully between contractions. Urine Ketosis may develop due to prolonged starvation.

Cont.
Fetal Fetal distressmay develop. Membrane rupture Membranes may or may not rupture early. In early rupture, there is a risk of infection of the uterine contents if proper antibiotics are not prescribed. The large intestines are dilated and can be palpated along both sides of theuterusas large, thick structures filled with air. They give off the hollow

Management of prolonged labour

Midwives are required to seek medical advice having recognized a deviation from normal and will normally will continue to provide care for the prolonged labour women & work with the interprofessional team to ensure a safe outcome

pattern

Diagnostic criterion 20 hours or more 14 hours or more < 1.2 cm / hour < 1.5 cm / hour

Prolonged latent phase Nulliparas Multiparas

Primary dysfunctional labour (protractional disorder) Prolonged deceleration phase (7-10 cm dilatation

Nulliparas Multiparas

Nulliparas Multiparas

3 hours or more 1 hour or more

Pattern Secondary arrest of dilatation Protracted descent Arrest of descent Prolonged 2nd stage

Diagnostic criterion Arrest 2 hours or more < 1cm / hour < 2cm / hour

Nulliparas Multiparas Arrest 1 hour or more No descent in the 2nd stage

Principles of care for a mother in labour are continued as for normal birth but with particular attention to the following : Informed choice and consent to treatment - the midwife should give as much as information available to ensure that the couple understand the event and to obtain consent to all aspect of treatment.

Psychological support - give emotional support by giving information that ensure the woman understands events, feels free to ask questions and is aware on how labour is progressing . Besides that, following any procedures, the midwife should provide feedback & verbal reinforcement. - offer Husband Friendly to patient to reduce her anxious. Communication - communication between personnel with liaison between the midwifery, obstetric & pediatric services should be clear to ensure

Analgesia - adequate analgesia should be offered to the mother such as IM Pethidine 75mg before dilatation os 5cm as prescribed by DR. Repeat analgesia if required as ordered by DR - Where labour is prolonged an epidural block may ne beneficial and affords complete pain relief in most cases.

Comfort & Cleanliness - general hygiene is important, especially where the membranes have been ruptured. Prolong contact with moisture can also give rise to tissue damage and soiled pads & bed linen should be changed as necessary - wet the patients lips as a comfort to patient Position - Encourage the mother to change the posture other than supine to fasten the progress of labour

Observations - temperature should be taken every 4 hours as infection may develop where there has been prolonged rupture of membrane - pulse and blood pressure are recorded hourly, or more frequently if the womens condition requires. All relevant observations are noted & should be recorded on the partogram or written in the clients record.

Empty bladder - in all stages of labour, the midwife should make sure that the women is able to pass urine but if she is not able to, then the women must be catheterized in order to help the descent of presenting part

Amniotomy/ artificial ROM - informed DR if membrane still intact & there is no progress in labour, so that DR can perform Amniotomy to fasten the labour. Administration of Oxytocin - Administer Oxytocin as prescribed by DR and according to local practice & if amniotomy does not bring good uterine contractions and there is no contraindication for it.

Assessment of progress in prolonged labour - asses the progress of contraction to detect for hypotonic uterine contraction which will cause prolong labour - asses on descent per abdomen via abdominal palpation - vaginal examination is carried out usually on a 4 hourly regime. - progress is noted in terms of increasing dilation, along with the consistency of the cervix to the presenting part.

- position of sagittal suture is also noted where in caput or moulding , position and station difficult to asses as it masks the sutures & fontanelles - descent of the presenting part also noted to see the labour progress. the colour of the amniotic fluid needs to be noted and if meconium is present this should be reported The midwife should use the partograph in early detec tion & responsible for letting the DR know

Fetal well being - monitor GTG continuously to determine fetal distress - FHR (tachycardia / bradycardia) - presence the accelaration is normal. - presence of decelaration which is abnormal - baseline variablity where loss of this variability may indicate fetal compromise. - the presence of meconium- stained liquor and an abnormal FHR tracing is suggesive of fetal hypoxia.

Any maternal or fetal distress is immediately reported to the DR & these conditions are treated by the midwife, pending the arrival of the DR. preparations are made foe either a CS if the first stage of labour is prolonged, or for an instrument delivery or CS in the second stage of labour - Caesarean section is indicated in:

Failure of the above measures. Disproportion. Malpresentations not amenable for vaginal delivery. Contraindications to oxytocin. Foetal distress.

Possible outcome of prolonged labour

To the mother Maternal distress and exhaustion (keto acidosis) Intrauterine infection from early rupture of the membranes and from excessive interference Overstretching of the pelvic floor , resulting in uterine prolapsed cystoceles and rectoceles Postpartum haemorrhage , atonics and traumatic

Psychological trauma from pain and inability to deliver normally Rupture of an old caesarean section scar

To the Fetus Fetal distress or compromise fetal hypoxia. Asphyxia neonatorum . Intracranial injury due to anoxia or due to trauma during birth. Intrauterine infection of the fetus leading to meningitis , septicaemia .