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 3 rd 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 Prolapse 2.Birth Asphyxia 3.Meconium Aspiration Syndrome 4.Convulsion 5.Jaundice 6.Neonatal Sepsis/Septicemia 7.Diarrhoea 8.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