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 contractions
2. Passenger i.e. the fetus
3. 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
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Infection – sepsis, peritonitis, wound infection,
Fistula
Thrombo-embolism
Ruptured Uterus
PPH
Broad Ligament Haematoma
Shock
Paralytic ileus
Burst abdomen
Fetal complications
1. Cord Prolapse
2.
3.
4.
5.
6.
7.
8.
Birth Asphyxia
Meconium Aspiration Syndrome
Convulsion
Jaundice
Neonatal Sepsis/Septicemia
Diarrhoea
Birth injury
An overview on pathophysiology of
prolonged obstructed labour
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Maternal exhaustion and distress
Hypovolaemia
Electrolyte imbalance
Thrombo-embolism
Other cpxs
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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