PROLONGED LABOUR

Fahad zakwan

NORMAL LABOUR• Defined as:

Presence of regular painful uterine contractions becoming progressively stronger and more frequent accompanied by

effacement and progressive dilatation of the cervix and decent of the presenting part.

• At its onset its usually accompanied by bloody mucoid vaginal discharge called show.

• The process culminates in expulsion of the baby and other products of conception.

The course of normal labour

1. The 1st stage of labour

(a)the latent phase

This is the period from 0 – 3 cm dilatation of the cervix.

Its duration can not be easily determined but perhaps around 8

hrs.

(b) The active phaseThis is the period from 3 – 10 cm (full dilatation)

dilation of the cervix.

In this stage the woman is said to be in established labour.

The cervix dilates at the rate of about 1 cm/hour

It may be a little faster esp. in multiparous women or little slower esp. in primigravida, giving an average

duration of labour of about 12 hrs.

2. The 2nd stage of labour

•This is the stage from full dilatation of the cervix to the delivery of the baby.

•It takes •1 hour in primigravidas •30 minutes in multigravidas

The 3rd stage of labour

This is the stage of labour after delivery of the baby to the delivery

of the placenta and membranes.

•It usually takes 15 minutes

The 4th stage of labour

•This is the stage in the first 24 hours after delivery

•This is the period where majority of maternal deaths occurs

•It needs close monitoring of the mother in the hospital esp. for PPH, Eclampsia etc..

PROLONGED LABOUR•Labour is said prolonged when it has lasted for over 12 hours since its establishment.

•However since it may not be possible to know exactly when it started in a particular women, failure to progress may be more significant than the actual duration.

CAUSES OF PROLONGED LABOUR

It is due to fault with the1. Passage2. Passenger3. Powers4. psyche

Passenger

infant size and fetal presentation, e.g., in cephalic-occiput anterior or

occiput posterior vs. breech or transverse)

passage• Pelvis size and adequacy of the bony pelvis as

well as soft tissues

• Conditions associated with faulty passage or passenger will usually lead to mechanical obstruction due to disproportion btw foetus and the maternal pelvis.

Pelvic diameters

Anterior-posterior(cm) Transverse (cm)

Brim 11 13.5

Cavity 12 12

outlet 13.5 11

diagonal 12.5

Power•Faulty powers means that the

expulsive forces are ineffective to overcome the normal resistance of

the birth canal.

OBSTRUCTED LABOUR

Failure of progressive descent of the presenting part , despite adequate uterine

contractions.

•It implies mechanical obstruction

•Cervical dilatation is usually arrested or occurs much slower.

CAUSESCephalopelvic disproportional (CPD)

• Small pelvis with a normal baby

• Big baby

• Shoulder dystocia

• Deformed pelvis (rickets, polio, Tb spine, fracture)

Abnormal presentation/position•Brow

•Face

•Breech especially after coming head

•OPP

Abnormal fetus–Hydrocephalus

–Locked twins

–Fetal ascites

Soft tissue abnormalities•Myoma in the lower segment or

cervix

•Cervical stenosis

•Vaginal stenosis

ANTICIPATION OF OBSTRUCTION DURING LABOR

Close surveillance of a woman in labor will identify obstruction before it

advances to cause maternal and/or fetal complications

The following parameters should raise suspicion

• Failure of progressive descent of the presenting part and/ or stagnation or slow dilatation of the cervix

• Cervix that is poorly applied to the fetal presenting part• Incoordinate uterine action• Early rupture of membranes• Reduced pelvic diameters• Diagonal conjugates of less than 11cm• Flat sacral curve• Prominent ischial spine• Narrow subpubic angle or pubic arc.

NEGLECTED OBSTRUCTED LABUR

•When labour is obstructed the uterus continues to contract long after.

• In neglected obstruction the duration of labour will be prolonged

•First stage will have lasted for many hours above the average of 12 hours and/or the second stage will have lasted for over an hour

• Most of the complications we encounter in obstructed labor are a result of neglects

• The obstruction is prolonged resulting in short and long term complications.

• The major immediate causes of death in obstructed labour are sepsis, and haemorrhage from uterine rupture.

• Sepsis is more common in primigravida women, and uterine rupture in parous women.

• in primigravida women, the uterus probably stops contracting because of myometrial acidification. This acidification results from local myometrial energy depletion, anaerobic metabolism, and systemic ketosis.

• In parous women, perhaps the myometrium becomes tolerant to the effects of acidification by an unknown mechanism and does not stop contracting. Continued contractions in the presence of myometrial energy depletion and hypoxia are likely to lead to myometrial oedema and necrosis contributing to uterine rupture.

Indicators of neglected obstructed labour

Metabolic changes

1. Hypoglycemia

2. Metabolic acidosis

3. Dehydration

4. Electrolyte imbalance

5. Ketonuria &Oliguria

Other features• Maternal exhaustion• Fever• tachycardia• Fetal distress and/or IUFD• Formation of bandl’s ring or peanut shaped uterus• Tonic inertia of the uterus• Excessive Caput formation• Excessive molding• Vulvae oedema

BANDL’S RING

COMPLICATIONS OF OBSTRUCTED LABOUR

•Uterine rupture

• IUFD

•Fistulae formation –VVF/RVF

•Sepsis

•Birth trauma

• Foetal asphyxia• Intracranial physical

damage• Postpartum

hemorrhage• Maternal perineal

injuries• Obstetric palsy

MANAGEMENT OF OBSTRUCTED LABOUR

(a)initial assessment of the patient• Pallor, pulse, blood pressure, dehydration

• Fundal height, foetal lie, foetal presentation, foetal heart rate, state of the uterus and bladder.

• Level of presenting part, cervical dilatation, caput formation and moulding.

• Do pelvic assessment and note the measurements and the presence of infected liquour.

• Access urine

• Blood group and Xmatch

(b) resuscitate the patient

• IV fluids at least 3L stat.

• Give dextrose saline for hypoglycemia initially then ringers lactate

(c) control infection

• Give broad spectrum IV antibiotics

• Stat dose of Ampicillin 1g and chloramphenicol 1g IV

(d) check if the foetus is alive and decide mode of delivery

(e) empty bladder with self retaining catheter

Principles of management

• Relieve the obstruction the earliest

• Pain relief

• Combat dehydration

• Prevent sepsis.

• Correct hypoglycemia

• Correct electrolyte imbalance.

MODE OF DELIVERY(a) If the foetus is alive delivery should be accomplished by

caesarean section.

• Swab of the amniotic fluid should be taken for bacteriological analysis

• If the head is deep in the pelvis it should be pushed up from the vagina by an assistant after opening of the uterus.

(b) If the foetus is dead and the cervix is fully dilated a destructive procedure may be fully undertaken. However if

the cervix is not fully dilated C/S should be done

Post delivery care

• Continue monitoring of temperature, pulse, Bp urine output and color

• Monitor abdominal distension

• Continue antibiotics

• Continuous bladder drainage for at least 10days

• Check for perineal nerve damage and rehabilitate accordingly

• Bear in mind possibility of Secondary PPH

• Counseling for future pregnancies and deliveries

anticipation of obs labor during ANC

• Short stature particularly in primes <150cm

• Large fetuses >4.0 kg

• Obvious pelvic/spinal deformities

• Gynetresia.(at least one pelvic exam be done at ANC

• Uterine myomas in lower segment or Cervix

• Abnormal lie

• Severe degree of overlap at pelvic brim

PROLONGED LABOUR DUE TO FAULTY POWERS

• The expulsive force during labour is comprised of:• Uterine contractions

• Maternal efforts• As reflex action coinciding with contractions

• As a deliberate effort by the mother to bear down

• When the normal expulsive forces are too weak to overcome the normal resistance from the birth canal labour fail to progress and becomes prolonged.

•Normal myometrial contraction and retraction leads to stretching of the lower segment and thickening of the upper segment.

• This coordination leads to fundal dominance and a resultant downward force during the process of child birth.

• Lack of coordination of the upper segment and lower segment leads to lack of fundal dominance hence abnormal uterine action.

Three types of abnormal uterine action have been recognized.

1. Incoordinate action

2. Uterine hypotonia (primary/ secondary)

3. Hypertonic dysfunction

Incoordinate action

Diagnosis• Infrequent irregular contractions

• Cervix fails to dilate or stagnates

• Severe colicky pain persisting even after the contraction have passed

• High intrauterine pressure >24 mmHg (persistently) leading to interference with placental circulation and causes foetal hypoxia and distress

Uterine hypotonia

•Urine contractions are of insufficient force and infrequent.

• There could be complete inertia

•Common causes include:• Over sedation• Overdistention of the uterus eg. In multiple pregnancy,

polyhaydromnious and big baby.• Secondary inertia in primigravidae could be due to

obstructed labour.

Treatment• In both incoordinate dysfunction and uterine

hypotonia, as long as obstruction is ruled out give:• Dilute IV oxytocin e.g.:

• 5 IU in 500 mls. of normal saline (20,30,40,50,60 drops/min)

•Care must be taken with oxytocin in multiparous women as the response of oxytocin might violent enough to cause uterine rupture

Complications of prolonged labour without obstruction

1. Sepsis – both maternal and foetal2. Maternal exhaustion3. Fetal hypoxia or distress4. PPH – both primary and secondary