1. Prolonged labour

3. Definition
The labour is prolonged when the combined duration of the first and second stage is more than the arbitrary time limit of 18 hours. [ D.C.Dutta] Prolonged labour is defined when the first and second stage of labour last more than 24 hours, currently duration is taken as more than 18 hours. Duration of labour is calculated from mother’s subjective estimate of labour onset [Dawn]

4. Prolongation due to Protracted cervical dilatation in the first stage
Inadequate descent of the presenting part during the first or in the second stage
Labour considered prolonged when the cervical dilatation rate is < 1 cm/hr and the descent of the presenting part is < 1 cm/hr for a period of minimum 4 hours observation.

5. Types of prolonged labour
Hypotonic uterine dysfunction: due to low intensity uterine contractions.
general factors local factors
Elderly primi gravida over distention of uterus
Anemia developmental anomalies
Nervousness, anxiety myomas of uterus
and fear
Hormonal mal presentations, CPD
Improper use of malpositions
analgesics full bladder and rectum

6. Cont… Hypertonic uterine dysfunction: it can be
Incordinate uterine action
colicky uterus
Asymmetrical uterine dysfunction
Hyperactive lower segment
Constriction ring dystocia
Cervical dystocia: cervix becomes thin and fails to dilate within a reasonable time inspite of good uterine contractions.

7. In coordinate uterine action
Cervical dystocia

8. Incidence
Primi gravidae 25% Multi gravidae 2%

9. Risk factors of prolonged labour
age and parity: commonly primigravidae, more in elderly one
CPD and fetal malposition
Uterine distention- twins, hydramnios
Uterine defect- fibroid, malformation
Nervousness, fear and emotion
injudicious use of analgesia in labour
injudicious induction of labour by ARM and oxytocin drip.
unknown cause.

10. Causes of prolonged labour
Faults in power [commonest cause]
*inefficient uterine dysfunction
*constriction ring
*cervical dystocia
*over dose of sedative and analgesics
* epidural analgesia
*improper use of oxytocics

11. Cont… Faults in passage: PROM Contracted pelvis CPD Cervical stenosis
Fibroid or carcinoma
Ovarian tumor
Uterine fibroid 20%

12. Engagement & descent of the foetal head -
presence of cephalopelvic disproportion

13. Engagement & descent of the foetal head -
presence of cephalopelvic disproportion

14. Cont… Faults in passenger: Occipito posterior positions of vertex
Other malpresentations
Twins
Hydramnios[ 30%]

15. Labour disorders due to inefficient uterine action
prolonged latent phase beyond 12 hours
Hypotonic or hypertonic dysfunction
Predisposing factors are sedation, anaesthesia , false labour,unknown cause.
Prolonged active phase[ protraction disorder]
Slow rate of cervical dilatation below 1cm/hr in nullipara and 1.5 cm/hr in multipara
Caused by hypotonic dysfunction, hyperactive lower segment.
Predisposing factors :CPD,fetal malpositions and sedation

16. secondary arrest of cervical dilatation or head descent
Cont…
secondary arrest of cervical dilatation or head descent
Arrest of cervical dilatation is taken when there is no cervical change for 2 hrs.
there is head descent less than 1cm/hr in nullipara or less than 2cm/hr in multipara and no head descent for one hour.
Due to hypotonic dysfunction and incordinate uterine dysfunction.
The causative factors are occipito posterior positions [70%], pelvic contraction ,excessive sedation.

17. DIAGNOSIS Clinical features Hypertonic dysfunction
[ less frequent]
Hypotonic dysfunction
[more frequent]
1. Timing of dysfunction [more frequent]
At latent phase from start of labour usually running to active phase
Latent phase from start of labour
Severely painful ,prolonged lasting, frequent pain as abdominal colic or as backache ,desire to bear down during contraction with incompletely dilated cervix.
Less painful, short lasting, infrequent abdominal pain and no back ache
2.Labour pains

18. Cont… 3.membranes Remains intact Ruptures early 4.Cervical dilatation
Slow .it hangs thick lipped without pressure of head.
slow
5.Fetal head
Caput develops late
Caput develops even before rupture of membranes
6.Fetal distress
Appears late
Appearing early

19. Cont…
She becomes distressed in pain, goes to dehydration and acidosis early.
7.Maternal effect
little
8.Difficult labour
Same in both groups

20. Cont… Other measures such as : radiography, CT or MRI
Abdominal and vaginal examination.
partograph

21. Cont… First stage: is considered prolonged
When the duration of labour is more than 12 hrs
The rate of cervical dilatation is < 1 cm / hr in a primi and < 1.5 cm/ hr in a multi
when the cervicograph crosses the alert line and falls on zone2
Intervention is required when the cervico graph crosses the action line and falls on zone 3

22. Cont…
Secondary arrest : is defined when the active phase of labour ( cervical dilatation ) commences normally but stops or slows significantly for 2 hrs or more prior to full dilatation of the cervix. It is commonly due to malposition or CPD

25. Cont… Second stage: is considered prolonged
When it lasts for more than 2 hrs in primi and 1 hr in multi.
Diagnosis :
Sluggish or non descent of the presenting part even after full dilatation of the cervix.( failure of head descent within 1 hr of full dilatation is called protraction of descent.)
Variable degrees of molding and caput formation in cephalic presentation.
Identification of the course of prolongation.

26. Dangers(Complications)
Maternal effects:
Distress
PPH
Trauma to genital tract
Increased operative delivery
Puerperal sepsis
Sub involution.

27. Cont… Fetal effects : Hypoxia Intra uterine infection
Intra cranial stress or hemorrhage
Increased operative delivery

28. Management Prevention :
Antenatal or early intra natal detection of the factors likely to produce prolonged labour.
Use of partograph
Selection and judicious augmentation of labour by low rupture of the membranes followed by oxytocin drip.
Change of posture in labour, other than supine to increase uterine contractions, avoidance of dehydration in labour and use of adequate analgesia for pain relief.

29. Cont… Actual Rx: Careful evaluation to find out
Cause of prolonged labour
Effect on the mother
Effect on the fetus

30. Cont… Definitive Rx : First stage
patient is referred to level 11 care without any solid food. Only water is allowed orally.
Maintain partograph
Identify or diagnosis of hypotonic and hypertonic labour dysfunction.
Monitor maternal vital signs and FHS
Identify CPD or fetal mal position.
Maintain I.V line with 5% DW/RL
Antibiotics ( cefazoline ) 1 gm I.V and repeated after 6 hrs on PROM

31. IN CASE OF PROM GROUP B: Hypertonic uterine dysfunction
Os 3 cm at 12 hrs labour since admission;
i.v. 5% DW and RL is set up
Nothing by mouth
Inj. Pethedine 100 mg, phenergan 25mg, continuous epidural or caudal analgesia if available.CPD is evaluated
FHR monitoring done on recovery from sleep , her hypertonic
dysfunction may improve.
Uterine hyper tone Uterus
Persists, fetal distress relaxes
AROM
C.S oxytocin, wait for
Vaginal delivery CS
GROUP A: Hypotonic uterine dysfunction
Os 3 cm on 12 hrs labour since admission on vertex presentation.CPD excluded.FHS normal
Artificial rupture of membrane , if liquor shows meconium CS. If liquor clear
wait for 60min. for improvement of contractions Otherwise – oxytocin 5 units.
500ml 5% dectrose in primi or 2 units in 500ml DW in multi.
Fetal monitoring is done. If failure to progress or fetal distress CS

32. Cont.. Group A:Second stage Group B:Second stage
Cervical dystocia, Duhrssen’s incision is made at 3 o’ clock and 9 o’ clock position on cervical lip by applying forceps or vacuum extractor, thus delivery is done. For constriction ring, vaginal delivery can be done under deep general anaesthesia if fetus is not distressed
Head at outlet,FHS normal; AROM. If membranes present followed by oxytocin drip for uterine dysfunction Failure to progress Low forceps/ vacuum extraction if late referral/ dead fetus/malformed fetus Oxytocin drip Craniotomy delivery

33. Cont… Third stage actively managed
Neonatal care is important due to meconium aspiration

34. Nursing diagnosis Risk for injury to mother and fetus
Fatigue and exhaustion related prolonged efforts and pain
Anxiety related to process and outcome of labour
Knowledge deficit related to labour process

35. Thank you