Affiliated to Purbanchal University

OM HEALTH CAMPUS
Gopikrishnanagar, Chabahil, Kathmandu

LESSON PLAN ON : PROLONGED LABOR

Submitted To: Submitted By:

Ms. Mamata Bhandari Sujina Rana Magar

Roll no: 29

BSN 4th Year (14th Batch)

LESSON PLAN
Subject : Midwifery II

Topic : Prolonged Labor

Date :

Time :

Duration : 2 hours

Venue : OM Health Campus (PCL 3rd year class)

Level of Learners : PCL Nursing 3rd Year

Number of Learners: 40

Name of Student : Sujina Rana Magar

Level of Student : Bsc.nursing 4th Year

Name of supervisor: Ms. Mamata Bhandari

General Objective:

At the end of this session, participants will be able to describe about Prolonged Labor.
S.N Specific Objectives Content Time

Greetings
Introduction
 Self
 Topic 5 minutes
Objectives
Pretest
At the end of the session, participants will be able to;

i) define prolonged labor Definition 10 minutes

ii) enlist the causes of prolonged labor Causes 15 minutes

iii) enlist the sign and symptoms of prolonged labor Sign and Symptoms 10 minutes

iv) list the diagnostic features of prolonged labor Diagnostic Features 10 minutes

v) explain the management of prolonged labor Management 40 minutes

vi) enlist the complications of prolonged labor Complications 10 minutes

Summarization
Post-test
Assignment 15 minutes
Reference
 Teaching Method Teaching Media Evaluation

Meta Card

Brainstorming What is prolonged labor?

Lecture + Discussion Powerpoint What is prolonged labor?

Lecture + Discussion Pamplet What are the causes of prolonged labor?

Lecture + Discussion News Print What are the signs and symptoms of
prolonged labor?

Lecture + Discussion Powerpoint What are the diagnostic features of

proloned labor?

Lecture + Discussion Powerpoint What are the management of prolonged

labor?

Lecture + Discussion Shape Card What are the complications of prolonged

labor?
 PROLONGED LABOUR
DEFINITION:
The labor is said to be prolonged when the combined duration of the first and second stage is
more than 18 hours without including false labor. The prolongation may be due to protracted
cervical dilatation in the first stage and/ or inadequate descent of the presenting part during the
first or second stage of labor. Inefficient uterine contraction can be a cause of prolonged labor
but labor may also be prolonged due to pelvic or fetal factor.

PROLONGED LATENT PHASE:. Mean duration of Latent phase is 8 hours in primigravida

and 4 hours in multigravida. A latent phase that exceeds 20 hours in primigravida or 14 hours
in multigravida is abnormal.

PROLONGED ACTIVE PHASE: 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. (1 or 1.5 cm/hour). The
rate of cervical dilatation is <1cm/hr in a primi and <1.5 cm/hr in a multi.

PROLONGED SECOND STAGE: The second stage is considered prolonged if it lasts for
more than 2 hours in primigravida and 1 hour in multigravida.

CAUSES OF PROLONGED LABOUR

1. Fault in power

2. Fault in passage

3. Fault in passenger
  FIRST STAGE:

Failure to dilate the cervix is due to:

1) Fault in power:
a) Abnormal uterine contraction such as uterine inertia (common) or inco-ordinate uterine
contraction.

2) Fault in the passage:

a) Contracted pelvis.
b) Cervical dystocia.
c) Pelvic tumor.
d) Full bladder.

3) Fault in the passenger:

a) Malposition and malpresentation.
b) Congenital anomalies of the fetus (hydrocephalus).

4) Others: injudicious (early) administration of sedatives and analgesics before the active
labor begins.

 SECOND STAGE:
1) Fault in the power:
a) Uterine inertia.
b) Inability to bear down.
c) Epidural analgesia.
d) Constriction ring.

2) Fault in the passage:

a) Cephalopelvic disproportion, android pelvis, contracted pelvis.
b) Undue resistance of the pelvic floor on perineum due to spasm or old scarring.
c) Soft tissue pelvic tumor.

3) Fault in the passenger:

a) Malposition (occipito-posterior).
b) Malpresentation.
c) Big baby.
d) Congenital malformation of the baby.
SIGNS AND SYMPTOMS:
1) Patient looks exhausted and distressed. Dehydration may be present. Mouth may be dry
due to prolonged mouth breathing.
2) 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.
3) Pulse rate is often high.
4) The large intestines are dilated and can be palpated along both sides of the uterus as
large, thick structures filled with air. They give off the hollow sound of drums on tapping.
5) The uterus is tender on palpation and does not relax fully between contractions.
6) Ketosis may develop due to prolonged starvation.
7) Fetal distress may develop.
8) Membranes may or may not rupture early. In early rupture, there is a risk of infection of
the uterine contents.

DIAGNOSTIC FEATURES:
1) First stage:
❖ First stage of labor is considered prolonged when the duration is more than 12 hours.

❖ The rate of cervical dilatation is <1 cm/hr in a primi and <1.5 cm/hr in a multi.

❖ The rate of descent of the presenting part is <1cm/hr in a primi and <2cm/hr in a multi.
2) Second stage:
❖ The second stage is considered prolonged if it lasts for more than 2 hours in primi and
1 hour in multi.
❖ Sluggish or non descent of the presenting part even after full dilatation of the cervix.

❖ Variable degrees of moulding and caput formation in cephalic presentation.

❖ Identification of the cause of prolongation.

MANAGEMENT:

1) General management:
 ⮚ Perform a rapid evaluation of the condition of the woman and fetus and provide
supportive care.
⮚ Test urine for ketones and treat with IV fluids if ketotic. In case of neglected
prolonged labor with evidence of dehydration and keto acidosis, correction of
ketoacidosis should be made urgently by rapid intravenous infusion of 5% dextrose
and Ringer’s lactate solution.
⮚ Review partograph.

⮚ Supportive care:

▪ Encourage support from the chosen birth companion.

▪ Arrange seating for the companion next to the woman.

▪ Encourage the companion to give adequate support to the woman during labor
and childbirth (rub her back, wipe her brow with a wet cloth, assist her to move
about).
▪ Explain all procedure and discuss finding with the woman.

▪ Ensure privacy and confidentiality.

▪ Wash the vulval and perineal areas before each examination.

▪ Encourage the woman to empty her bladder regularly.

▪ Encourage to drink nutritious liquid drinks.

▪ Teach breathing techniques for labor and delivery.

▪ Give her praise, encouragement and reassurance. Give her information on the
process and progress of her labor.

2) Obstetrical management:
❖ For first stage delay:

⮚ Vaginal examination.

⮚ Clinical pelvimetry is done.

⮚ If only uterine activity is suboptimal, then:

 a) Amniotomy and/ or oxytocin infusion is adequate.
b) Effective pain relief.
c) Caesarean section is done when vaginal delivery is unsafe (malpresentation,
malposition, big baby, or CPD).
❖ For second stage delay:

⮚ FHR monitoring (electronic monitoring).

⮚ Vaginal delivery is imminent.

⮚ Otherwise, appropriate assisted delivery vaginal (forceps, ventouse) or

abdominal (caesarean) should be done.

3) During 1st stage:

❖ Prolonged latent phase:
When contractions become regular and dilatation progresses beyond 4 cm, the
woman is said to have been in the latent phase. If the woman has been in the latent
phase for more than 8 hours and there is little sign of progress, reassess the situation
by assessing the cervix, as follows:
⮚ If there has been no change in cervical effacement or dilatation and there is no
fetal distress, review the diagnosis. The woman may not be in labor.
⮚ If there has been a change in cervical effacement or dilatation, the membranes
should be ruptured with an amniotic hook or a kocher clamp and labor should
be induced (using oxytocin).
▪ The woman should be assessed every 4 hours.

▪ If she has not entered the active phase of labor after 8 hours of induction,
(oxytocin infusion), she should be delivered by C/S.
⮚ If there are signs of infection (fever, foul-smelling vaginal discharge), labor
should be augmented immediately with oxytocin. Combination antibiotics
should be given until delivery as:
Ampicillin 2g IV every 6 hours and Gentamycin 5mg/kg body weight IV every
24 hours.
▪ If the woman delivers vaginally, discontinue antibiotics.
 ▪ If the woman has a caesarean section, continue antibiotics plus give
metronidazole 500 mg IV every eight hours until the woman is fever free for
48 hours.

❖ Prolonged active phase:

⮚ If there are no signs of cephalopelvic disproportion or obstruction and the

contractions are regular and strong and the membranes are intact, the
membranes should ruptured with an amniotic hook or a kocher clamp.
⮚ Assess uterine contractions:

▪ If contractions are inefficient (less than 3 contractions in 10 minutes each

lasting less than 40 seconds), suspect inadequate uterine activity and refer to
higher level care.
▪ If contractions are efficient (3 or more contractions in 10 minutes, each lasting
more than 40 seconds), suspect cephalopelvic disproportion, malposition or
malpresentation and refer to higher level care.
⮚ Continue to monitor maternal and fetal well-being and the progress of labor
and be prepared to refer to higher level care if normal progress does not
resume.
⮚ Provide general methods of labor support that may improve contractions and
accelerate progress.
⮚ Encourage the woman’s birth companion to give adequate support.

⮚ Explain all procedures to the woman.

⮚ Provide a supportive, encouraging atmosphere for the birth.

⮚ Encourage her to empty the bladder regularly.

⮚ Encourage breathing techniques.

4) During 2nd stage:

 ⮚ Maternal expulsive efforts increase fetal risk by reducing the delivery of
oxygen to the placenta, while spontaneous maternal ‘pushing’ should be
allowed, prolonged effort and holding the breath should not be encouraged.
⮚ If malpresentation and obvious obstruction have been excluded, augment
labor with oxytocin.
⮚ If there is no descent after augmentation:

▪ If the fetal head is not more than 1/5 above the symphysis pubis or the
leading bony edge of the fetal head is at 0 station, delivery by vacuum
extraction or forceps.
▪ If the fetal head is between 1/5 and 3/5 above the symphysis pubis or the
leading bony edge of the fetal head is between 0 station and -2 station:
a) Deliver by vacuum extraction and symphysiotomy.
b) If the operator is not proficient in symphysiotomy, deliver by caesarean
section.
▪ If the fetal head is more than 3/5 above the symphysis pubis or the leading
bony edge of the fetal head is above -2 station, deliver by caesarean
section.

NURSING CARE:

1) Reassure the patient and her family.

2) The midwife should help her to adopt a comfortable position and should assist the partner
to provide continual support and encouragement.
3) Observe mother’s general condition and state of hydration.
4) Intravenous infusion is given according to order.
5) Regular monitoring of vital signs, contraction and fetal heart sounds.
6) The woman should be encouraged to empty her bladder regularly.
7) Maintain fluid balance chart.
8) Vaginal examination to ascertain the presentation of fetus.
9) If the membranes have been rupture for more than 24 hours a high vaginal swab may be
taken for culture and sensitivity.
10) Administer antibiotic as ordered.
11) Administer oxygen in case of fetal distress.
12) Record and report.
DANGERS:
1) Fetal:
The fetal risk is increased due to the combined effects of:
a) Hypoxia due to diminished utero placental circulation specially after the rupture of
the membranes.
b) Cerebral palsy.
c) Intracranial stress or hemorrhage following prolonged stay in the perineum and/or
super moulding of the head.
d) Increased operative delivery.
e) Prolonged second stage of labor is often associated with variable and delayed
decelerations. Scalp blood pH estimations show fetal acidosis. All these result in
increased perinatal morbidity and mortality.

2) Maternal:
There is increased incidence of:
a) Maternal distress.
b) Postpartum hemorrhage.
c) Trauma to the genital tract such as cervical tear, rupture uterus.
d) Intrauterine infection.
e) Increased operative delivery.
f) Postpartum infection or puerperal sepsis.
g) Sub involution.
The sum effects of all these lead to increased maternal morbidity and also increased
maternal deaths.

References

1) Dutta, D.C. (2018), “Textbook of Obstetrics”, New Central Book Agency (P) Ltd.,
Calcutta, India, 9th edition, Page no. 402-404.
2) Subedi, D, Gautam, S (2010), “Midwifery Nursing Part-II”, Medhavi Publication,
Bnaeshwor, Kathmandu, 1st edition, Page no. 190-194.
3) Tuitui, R (2010), “Manual of Midwifery II”, Vidyarthi Pustak Bhandar, Bhotahity,
Kathmandu, 7th edition, Page no. 289-290.