1. Prevention, Diagnosis and Treatment of protracted Labor
Dr. Mohammed Abdalla

2. Guideline Objective
To prevent unnecessary protracted labor
To increase the use of procedures that assist in progress to vaginal birth

3. Unsatisfactory progress of labour
Cervix not dilated
No palpable contractions/infrequent contractions
False labour

4. Unsatisfactory Progress of Labour
Cervix not dilated beyond 4 cm after 8 hours of regular contractions
Prolonged latent phase

5. Unsatisfactory progress of labour
Less than three contractions in 10 minutes, each lasting less than 40 seconds
Inadequate uterine contractions

6. Unsatisfactory Progress of Labour
Cervical dilatation to the right of the alert line on the partograph
Prolonged active phase

7. Unsatisfactory progress of labour Cephalopelvic disproportion
Secondary arrest of cervical dilatation and descent of presenting part in presence of good contractions
Cephalopelvic disproportion

8. Unsatisfactory progress of labour
Secondary arrest of cervical dilatation and descent of presenting part with large caput, third degree moulding, cervix poorly applied to presenting part, oedematous cervix, ballooning of lower uterine segment, formation of retraction band, maternal and fetal distress
Obstruction

9. 1. Confirm Active Labor Before Admitting to Facility
Spontaneous contractions at least 2 per 15 minutes,
and two or more of the following :
Complete effacement of cervix
Cervical dilation greater than or equal to 3 cm
Spontaneous rupturing of membranes (SROM)

10. 2. Perform Amniotomy Early in Labor
Spontaneous rupture of membranes
Presentation unknown, floating or unstable
Cervix dilated less than 3 cm
Patient refuses
Perform amniotomy early in labor
unless one or more of the following occurs:

11. 3-conduct Frequent Cervical Checks
Cervical checks should indicate at least 1 cm dilation per hour
Failure to progress is defined as
cervical changes of less than 1 cm per hour
for 2 consecutive hours.

12. Partograph and Criteria for Active Labor
Label with patient identifying information
Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given
Plot cervical dilation
Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour
Action line: if patient does not progress as above, action is required
The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor.
At the alert line, the onset of the active phase of labor (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labor.

13. 4-Augment with Oxytocin to achieve adequate labor for 2 to 4 hours.

14. In multigravida and in previous C.S.
2.5 U Oxytocin in 500 ml. G. 5%
In multigravida and
in previous C.S.
15 drops / min
increase infusion rate by 15 drops
every 30 minutes
When contractions lasting more than 40 seconds
and occurring three times in 10 minutes).
maintain infusion
If good contractions are not established
at 60 drops per minute .
5 units in 500 mL dextrose
30drops / min
increase infusion rate by 15 drops
every 30 minutes
If good contractions are not established at 60 drops per minute do c.s.

15. increase infusion rate by 15 drops increase infusion rate by 15 drops
5 units Oxytocin in mL dextrose
In primigravida
30 drops / min
increase infusion rate by 15 drops
every 30 minutes
When contractions lasting more than 40 seconds
and occurring three times in 10 minutes). maintain infusion
If good contractions are not established 60 drops per minute .
10 units in 500 mL dextrose
30 drops / min
increase infusion rate by 15 drops
every 30 minutes
If good contractions are not established at 60 drops per minute do c.s.

16. Uterine Hyperstimulation
Is defined as contractions lasting longer than 90 seconds, OR more than five contractions in 10 minutes
can be managed by changing the maternal position
and administering oxygen,
shutting off the pitocin until recovery has occurred
and possibly the administration of terbutaline 0.25 mg SC.

18. Category Definition
Normal A CTG where all four features fall into the reassuring category.
Suspicious A CTG whose features fall into one of the non-reassuring categories and the remainder of the features are reassuring.
Pathological A CTG whose features fall into two or more non-reassuring categories or one or more abnormal categories.

19. 5-If patient is in Stage II labour and is not making progress
Positioning.
Fluid balance.
Oxytocin augmentation.
Obstetrical/surgical consult.

20. 6- Consider operative vaginal delivery or cesarean delivery
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