Prolong Labour

Definition
The prolonged labour is defined when the combined duration of the first and second stage
of labour is more than the arbitary time limit of 18 hours. Labour is considered prolonged when
the cervical dilatation rate is less than 1cm/hr and descent of the presenting part is <1cm/hr for a
period of minimum 4 hours observations. It is calculated from mothers subjective estimate of
onset of true labour.

Prolonged latent phase: the latent phase is from onset of regular painful contraction with
cervical dilatation upto 4cm. If cervix is not dilated beyond 4cm for 8 hours of regular
contraction is considered as prolonged latent phase.

Prolonged active phase: the active phase is period from cervical dilatation 4-10cm.
Regular painful contractions with cervical dilatation more than 4cm last longer than 12
hour is considered as prolonged active phase. If the cervical dilatation arrests more than 2
hours is considered as abnormal.

Cervix is fully dilated and woman has urge to push but no descent is called prolonged
expulsive phase.

The second stage is considered prolonged if it lasts for more than 2 hours in primigravida
and 1 hours in multipara.

Causes of prolonged labour

First stage: failure to dilate cervix is due toi. Fault in power:- abnormal uterine contraction such as uterine inertia or hypotonic uterine
dysfunction (common), incordinate uterine contraction or hypertonic uterine dysfunction.
ii. Fault in the passage:- contracted pelvis, cervical dystocia, pelvic tumour or even in full
bladder, minor degree of pelvic contraction.
iii. Fault in the passenger:- malposition (OP) and malpresentation (face, brow), congenital
anomalies of the fetus (hydrocephalus), deflexed head.
iv. Others:- injudicious (early) administration of sedatives and analgesic before the active labour
begins.

Second stage

Fault in power:- uterine inertia, inability to bear down, epidural analgesia, constriction
ring.

Fault in the passage:- CPD, Contracted pelvis, android pelvis, soft tissue pelvic tumour,
undue resistance of the pelvic floor or perineum due to spasm or old scarring.

Fault in the passenger:- malposition, malpresentation , big baby, congenital

malformation of the baby.

Sign and symptoms

Labor extend for more than 18 hours

The rate of cervical dilatation is less than 1cm/hour in primigravida and less than 1.5
cm/hour in multipara in first stage of labor.

There may be slow descent of head or non descend of presenting part even after full
dilatation of cervix.

Patient looks exhausted and distressed

Pain may be more on the radiating to the thighs rather than within abdomen due to
pressure on muscle and ligaments.

Pulse rate often high

The uterus is tender on palpation does not relax fully between contraction.

Variable degree of moulding and caput formation is cephalic presentation.

Fetal distress may develop.

Membranes may or may not rupture.

Ketoacidosis may develop due to prolong starvation.

Risk of prolonged labour

Fetal risk

Hypoxia due to decreased uteroplacental circulation.

Intrauterine infection

Intracranial stress or hemorrhage following prolonged stay on perineum

Increased operative delivery

Increased risk of perinatal loss

Mother risk

Maternal distress

Intrauterine infection

Trauma and injuries in birth canal eg cervical tear, rupture of uterus

PPH

Postpartum infection or puerperal sepsis

Subinvolution

Diagnosis

History of prolonged labour

Abdominal examination

Per vaginal examination

Partograph- recording of maternal and fetal condition.

Intranatal radiography.

Management of Prolonged Latent Phase

If the woman has been in the latent phase for more than 8 hours and there is little sign of
progress, reasses the situation by assessing the cervix as follows:

If there has been no change in cervical dilatation or effacement and no fetal distress,
review the diagnosis. She may not be in labour.

If any changes in cervical effacement or dilatation, membrane should be ruptured and

labour should induced.

The woman should assessed every 4 hourly

If she has not been enterd in active phase after 8 hours of induction, delivered by
caesarean section

If there is sign of infection immediately augment the labour with oxytocin and antibiotics
should be given like ampicilin and gentamycin untill delivery.

If not delivered vaginally delivered by caesarean section and continue antibiotics plus
metronidazole for 48 hours

Management of Prolonged Active Phase

If there is no sign of CPD and good contraction with membrane intact, ruptured the
membrane artificially.

Assess uterine contraction

- If contractions are inefficient ( <3contraction in 10 minutes lasting less than 40 sec)

suspect inadequate uterine activity and refer to higher center.
- If contraction are efficient(3 or more contractions in 10 minute lasting more than 40 sec)
suspect CPD, malposition or malpresentation and refer to higher level.

Continue to moniter maternal and fetal wellbeing and progress of labour.

Encourage the womans birth companion to give adequate support.

Explain all procedure to the woman.

Provide supportive, encouraging atmosphere for the birth.

Encourage her to empty her bladder regularly.

Encourage breathing technique.

Mangement of prolonged expulsive phase

If malpresentation and obvious obstruction have been excluded, augment labour with
oxytocin.

If there is no descent (fetal head is at 0 or -2 station) after augmentation delivery by

vaccum extraction or forceps or symphysiotomy.

Abnormal Uterine Contraction

Normal labour is characterized by coordinated uterine contraction associated with

progressive dilatation of the cervix and descent of the fetal head within the specified time limit.
Any deviation of the normal pattern of uterine contraction affecting the course of labour is
termed as disordered or abnormal uterine action.
Etiology of abnormal uterine contraction

Elderly primigravidae

Prolonged pregnancy

Over distended uterus due to twins or hydramnious

Psychological factor

Contracted pelvis

Malpresentation

Full bladder

Injudious administration of sedatives, analgesics and oxytocics

Premature attempt of vaginal delivery or attempted instrumental delivery under

anesthesia.