Prolonged Labour

Mrs. Shwetha Rani C.M.

Associate Professor & H.O.D.
Department of Obstetric & Gynecological Nursing
SCPM College Of Nursing & Paramedical Sciences,
Gonda. U.P.
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.”
Failure to progress normal childbirth
process.
• 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).
• Prolonged labour is not synonymous with inefficient uterine
contraction can be a prolonged labour but labour may also be
prolonged due to pelvic or fetal factor.
Prolonged Latent Phase
• 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.
• Whether prolonged latent phase has got any adverse effect on the
mother or on the fetus, it is not clearly known.
• A latent phase that exceeds 20 hours in primigravidae or 14 hours in
multiparae is abnormal.
• 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.
• Expectant management is usually done unless there is any indication
(for the fetus or mother) for expediting the delivery.
• Rest and Analgesic are usually given
• When augmentation is decided, medical methods ( oxytocin or
prostaglandin) are preferred.
• Amniotomy is usually avoided.
• Prolonged latent phase is not an indication for cesarean section
delivery.
Causes of Prolonged Labour

First Stage.

Fault in
Power.

Fault in
Passage.

Fault in
Passenger.
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.
 SECOND
STAGE

FAULT IN
POWER

FAULT IN
PASSAGE

FAULT IN
PASSENGER
• Sluggish or non-descent of the presenting part in the second stage is due to:-
• FAULT IN POWER
• Uterine Inertia, Inability to bear Down, Epidural Analgesia, Constriction Ring,
• FAULT IN PASSAGE
• Cephalopelvic disproportion, Android pelvis, contracted pelvis, undue
resistance of the pelvic floor or perineum due to spasm or oldscarring.
• FAULT IN PASSENGER
• Malpostition (occipito-posterior), Malpresentation, Big Baby, Congenital
Malformation of the baby.
Diagnosis
• 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 reasonably established.
• Intranatal imaging ( radiography, CT or MRI) is of help in determining
the fetal station and position as well as pelvic shape and size.
• FIRST STAGE
• Duration is > 12 hours
• Cervical dilatation rate < 1 cm/hr in primi and < 1.5 cm/hr
• Rate of descent of presenting part is < 1 cm/hr in primi and < 2
cm/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
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
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.
DISORDERS OF SECOND STAGE
A) Protraction Descent
• When:-
• Descent of presenting part is < 1 cm/hr in nullipara and < 2 cm/hr in
multipara
• May be due to one or combination of several underlying
abnormalities like CPD, Malposition, Malpresentation, Inadequet
uterine contraction
Dangers
Hypoxia

Increased Intra
Operative
Delivery
Fetal Uterine
Infection

Intra Cranial Stress

or Haemorrhage
 Distress

Sub
PPH
Involution

Maternal

Genital
Puerperal
Tract
Sepsis
Trauma

Increased
Operative
Delivery
Traetment
• PREVENTION:-
• Antenatal or early intranatal detection
• Use of partograph
• Selective and injudicious augmentation
• Change of posture in labour
• 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: Inadequate uterine activity, primary
dysfunctional labour
• In multiparous women: CPD,
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
SECOND STAGE DELAY
• Short period of expectant management is reasonable provided the
FHR is reassuring and vaginal delivery is eminent
• Otherwise, appropriate assisted delivery , vaginal or abdominal
should be done.
• Difficult instrumental delivery should be avoided.