Labor is said to be prolonged when the combined duration of both the first and second stage of labour is more than 18 hours.
It is more common in a primi-gravidae and in women over the age of 35 years.
Prolonged labour is associated with increasing risks to mother and fetus.
Prolonged labour is most common in primi-gravidae and may be caused by:
– Ineffective uterine contractions
– Cephalopelvic disproportion
– Occipitoposterior position
– Use of Sedatives and Anesthesia
Signs and Symptoms of Prolonged Labour
· Labor extends for more than 18 hours.
· Dehydration may be present. Mouth may be dry due to prolonged mouth breathing.
· Pain may be more on the back radiating to the thighs rather than inside the abdomen. This is due to pressure over the muscles and ligaments.
· Labor pains may initially be severe, frequent and prolonged but later decrease and become very mild as the muscles become fatigued.
· Pulse rate is often high.
· Ketosis may develop due to prolonged starvation.
The first stage of labour is divided into a latent and an active phase. During the latent phase the uterus contracts regularly, and the mother experiences discomfort and pain. The cervix effaces and dilatation occurs. The duration of the latent phase will vary according to each individual and with parity.
Prolonged latent phase
The latent phase of labour is still poorly under-stood and its duration difficult to define, therefore a diagnosis of a prolonged latent phase may be inaccurately diagnosed when the mother is in false labour. It can also be mistakenly considered to be inefficient uterine activity and intervention wrongly occurs.
Prolonged active phase
The active phase is distinguished by an increase rate of dilatation of cervix, with descent of the presenting part. Slow progress may be defined either in total duration of hours in labour or failure of the cervix to dilate at a fixed rate per hour. A rate of 1 cm per hour is most commonly used. A prolonged active phase is caused by a combination of factors including the cervix, the uterus, the fetus and the mother, pelvic.
Assessment of the contractions
· Give information on the nature of contractions.
· Palpation of the fundus and External topographic assessment during the contraction allows the nurse to assess frequency and duration and gives some indication of the strength.
· Strength of the contractions can be difficult to assess because of the size of the abdomen and the contour of the uterus.
Normal uterine action
Normal uterine action is potentiated in labour by increasing levels of prostaglandin and oxytocin receptors. The myometrium contracts and retracts its efficiency dependent on fundal dominance and polarity between the upper uterine segment and the lower segment .The harmony is facilitated by the appearance in the myometrium toward the end of pregnancy of gap junctions. These gaps play a role in allowing electrical impulses to pass between the muscles.
The effectiveness of the contractions is further influenced by resistance, especially from the cervix and other soft tissues, size and position of the fetus and maternal pelvis.
Inefficient uterine action
- Slow progress in labour is often attributed to inefficient uterine contractions. In the absence of effective contractions, descent of the presenting part will be delayed, as muscle needs to have an adequate energy to contract effectively.
- The practice of restricting food and fluids to labouring mothers may have a detrimental effect on the contractions.
- Mother should be encouraged to continue with a light diet.
- The upright position of the labouring mother allows the uterus to fall forward, improves the application of the presenting part onto the cervix and may trigger the neuroendocrine Ferguson reflex.
- If the mother adopts an upright position, contractions have been found to be less painful although stronger and more efficient than when remaining recumbent.
- Stress is known to affect the contraction, and it is possible that less tension, as a result of mobility, the enhances the activity.
· Informed choice and consent to treatment
· Comfort and analgesia
Where labour is prolonged an epidural block may be beneficial and afford complete pain relief in most cases. Attention should be paid to ensuring that the woman is able to adopt the most comfortable position. General hygiene is important, especially where the membranes have been ruptured and soiled pads and bad linen should be changed a necessary.
– Temperature should be taken 4 hourly.
– Infection may develop where there has been prolonged rupture of membranes.
– Vaginal swabs may be taken and broad spectrum antibiotics commented when infection is suspected.
– Pulse and blood pressure are recorded hourly or more frequently if the woman’s condition requires.
· Fluid balance
– An accurate record should be kept.
– Note of urinary output is important
– The mother is offered the opportunity to empty her bladder every 2 hours.
– A full bladder may affect the uterine action in labour and if she is unable to void, a catheter should be inserted.
· Assessment of progress in prolonged labour
Vaginal examination is carried out, usually on a 4 hourly regimen. Progress is noted by increasing dilation along with the consistency of the cervix and application of the cervix to the presenting pat. Position of the sagittal suture is noted, as is any caput or moulding of the fetal skull. Moulding is an indication that the fetus is experiencing difficulty in negotiating the pelvis. The degree of moulding should be noted and any increase, over successive examinations, reported. Caput succedaneum can develop, particularly if labour is prolonged. This can make position and station of difficult to assess, as it masks the sutures and fontanelles.
Descent of the presenting part can be demonstrated by correlating findings from an abdominal examination and station of the presenting part on vaginal examination.
The colour of amniotic fluid needs to be noted and if meconium is present this should be reported.
· Fetal well-being
– Fetal heart should be to monitored continuously
– The use of oxytocin and epidural analgesia combined with maternal and fetal indications for induction have been cited as reasons for using electronic monitoring.
– Fetal blood sampling may be used to support decision to continue with labour, or intervene.
Prolonged Second Stage of Labour
Provided that there is evidence of descent of the fetus, is the absence of fetal or maternal distress there is no basis for placing a time limit on the duration of the second stage of labour.
There is no benefit to the mother or fetus in aggressive pushing to speed up of this stage of labour.
Adopting an upright position has been found to be advantageous to the mother, although opportunity may be limited be epidural block, infusion or fetal monitors.
Causes of delay in the second stage
Ineffective contractions, poor maternal effort, loss of, or absence of, a desire to push caused by epidural analgesia may all contribute to a lengthy second stage. A full bladder or a full rectum can also impede progress. A large fetus, malpresentation and malposition may account for delay and an assisted birth may be necessary.
A reduced pelvic outlet, in association with an occipitoposterior position, may result in deep transverse arrest. This occurs where advance of the presenting part is prevented as the occipitofrontal diameter becomes caught at the ischial spines.
Management of a prolonged second stage of labour
A vaginal examination should be carried out to confirm position, attitude and station of the presenting part. The fetal heart should be auscultated after every contraction or electronic monitoring used.
In the presence of inefficient uterine contractions an infusion of oxytocin should be commenced. The usual observations for the use of oxytocin apply.
Where there are related factor such as pre-eclampsia or prematurity, management of the second stage will be assessed constantly.
Where the mother is in labour at home the nurse should arrange for transfer to hospital or seek support via her supervisor of nurse.
Option for birth
Delivery may be expedited where the conditions alter and mother or fetus becomes distressed. The obstetrician will decide on method of delivery. Ventouse or forceps will be utilized where the pelvic outlet is adequate and vaginal birth can be safely carried out. Caesarean section may be necessary where evidence of Cephalopelvic disproportion is.