PROLONGED LABOUR

Hassan, MD

PROLONGED FIRST STAGE OF LABOUR

Diagnosis • Deviation of line of cervical dilatation to the

right of the alert line and reaches the action line.

Causes  1.   Powers i.e. uterine contractions2.   Passenger i.e. the fetus3.   Passage i.e. the pelvis.

Prolonged Latent Phase

• Diagnosis– Diagnosis of labor has been made but progressive

cervical change occurs but at an inordinately slow pace

• Causes– Unripe cervix, false labor, sedation, uterine inertia

• Complications– Maternal fatigue/exhaustion due to lack of sleep,

– Maternal dehydration that can lead to a combination of contractures and contractions

Prolonged Active Phase

Causes

• Power: Ineffective contractions

– Either they space out or have less strength to get the

effect needed.

– Causes - maternal fatigue, pain (catacholamine

response), overmedication either in dose or timing.

• Passenger: Big baby, malposition/presentation

• Passage: contracted pelvis

PROLONGED FIRST STAGE OF LABOUR

Active management of labour

Indications• Accurate diagnosis of Labour

• Primigravidae

• Singleton fetus

• Vertex presentation

• No evidence of fetal distress

PROLONGED SECOND STAGE OF LABOR

• Diagnosis– When the time exceeds 2 hours

• Causes: Descent abnormalities– Fetal position/malpresentation/size

– Ineffective contractions

– Ineffective maternal effort

– Medications/anesthesia

PROLONGED SECOND STAGE OF LABOUR

• Management – Depends on the cause.

• Poor uterine activity may be corrected by augmentation.

• Poor maternal effort or exhaustion - assisted delivery (as long as all the pre-requisites have been fulfilled).

PROLONGED THIRD STAGE OF LABOUR

Diagnosis

– When exceeds 30 minutes

Causes

1. Uterine atony

Big uterus due to poly, multiple pregnancy, myoma,

following prolonged labour, traumatic delivery,

excessive analgesia, anaesthesia

2. Uterine abnormalities – uterus & cervix

PROLONGED THIRD STAGE OF LABOUR

Causes

3. Placental abnormalities

Problems of adhesion: placenta praevia, cornual

implantation, accreta, pancreta etc

4. Mismanagement of 3rd stage

• Massage of uterus before delivery of the placenta

may lead to tetanic contractions,

• Admin of ergot preparations too early or too late

sustained uterine contration –traps the placenta

Occipito-Posterior Positions and Deep Transverse Arrest

• Occiput usually lateral when head engages 80% will rotate to anterior during labour

• POPP– Causes delay in lst stage.

– More common in primigravidae.

– Treatment if inefficient uterus action may result in rotation to anterior.

Occipito Posterior Position

Causes• Anteriorly situated placenta

• Anthropoid pelvis

• Flat Sacrum

• Pundulous abdomen

• Chance

• R.O.P. three times as common as L.O.P.

Occipito Posterior Position

Management• 12% will deliver spontaneously O.P.

• Transverse arrest may require operative intervention

• Lack of progress may warrant c-section

• Vacuum preferable to Forceps (?)

Complications of prolonged obstructed labour

Maternal

• Infection – sepsis, peritonitis, wound infection, • Fistula• Thrombo-embolism• Ruptured Uterus• PPH• Broad Ligament Haematoma• Shock• Paralytic ileus• Burst abdomen

Fetal complications

1. Cord Prolapse2. Birth Asphyxia 3. Meconium Aspiration Syndrome4. Convulsion5. Jaundice6. Neonatal Sepsis/Septicemia7. Diarrhoea8. Birth injury

An overview on pathophysiology of prolonged obstructed labour

• Maternal exhaustion and distress• Hypovolaemia• Electrolyte imbalance • Thrombo-embolism• Other cpxs

• Ruptured Uterus• PPH– Obstetric fistulae – Infection, paralytic ileus

Management of prolonged obstructed labour

• Resuscitation: IV fluids RL or NS 1-2 Lfast, use large bore cannula

• Catheterization – continuous bladder drainage• Blood gpg & x-matching• Antibiotics: i.v Ampicilin & metronidazole,

ceftriaxone

• Deliver the mother by CS

PRECIPITOUS LABOR

• Cervical dilatation rate– >5cm/hr dilatation in nullips; >10cm/hr in

multips

• Complications of precipitous labor– Trauma to birth canal;

– Fetal distress; and

– Postpartum hemorrhage