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 • Uterine atony Big uterus due to poly, multiple pregnancy, myoma, following prolonged labour, traumatic delivery, excessive analgesia, anaesthesia • 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 3rd 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 Cord Prolapse Birth Asphyxia Meconium Aspiration Syndrome Convulsion Jaundice Neonatal Sepsis/Septicemia Diarrhoea 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.vAmpicilin & 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