PROLONGED LABOR
By Laston Kastom Bsc BMS (RH), Dip.Clin.Med
BACKGROUND INFORMATION
Labor is said to be prolonged when the combined duration of both the first stage and second
stages of labor is more than 18 hours. It is more common in a first pregnancy and in women over
the age of 35 years.
TYPES OF PROLONGED LABOUR
Prolonged latent stage of labour
This is when a patient who was admitted in labour has not reached the active phase after 8 hours.
We have two different situations in this latent phase; the first one is the false latent labour while
the other one is the true latent labour
False labour is common in nuliparas and it is when the cervix is closed or admits only a finger
in prims and only 1 or 2 cm in multigravidas and you have no palpable contractions or infrequent
contractions
True prolonged latent phase is either the cervix is 100% effaced but stays stationary at about
2cm or it effaces and dilates very slowly
Prolonged Active Stage of Labour
In this stage of labour you can have two common situations, the first one is the protracted active
phase and the second one is the secondary arrest.
The protracted active stage is when the cervix dilates too slowly right from the beginning of
the active phase
The secondary arrest is when the cervix first dilates more or less normally but then stops
dilating altogether, usually the arrest occurs when the dilatation is around 6 or more, and it is
most often complicated by oedema of the cervix
CAUSES OF PROLONGED LABOUR
Malpresentations: The normal position of the fetus is longitudinal with the fetal spine
parallel to the mother's spine. The fetus lies in a completely flexed position with the chin
touching the chest and the arms and legs flexed in front. The fetus normally faces the
mother's back for a smooth delivery.
Any change in this position can cause prolongation in the duration in labor. A breech
presentation in which the fetus is in the buttocks down position, a face presentation in
which the fetus faces the mother's abdomen, or a deflexed position of the head in which
the neck of the fetus is less flexed or even straight or extended can all cause prolonged
labor.
Cephalopelvic Disproportion (CPD)
CPD is said to occur when the size of the fetal head is bigger than the size of the maternal
pelvic passage or birth canal. In most pregnant women in labor, ligaments and joints tend
to become more flexible, enabling them to relax more at the time of labor.
The baby's skull bones are also capable of overlapping each other normally to some
extent, decreasing the size of the head 'moulding'. So, it is difficult to estimate by
physical examination alone if CPD is actually present.
But if labor is unduly prolonged and no other cause is detected, a diagnosis of CPD is
usually made.
True CPD occurs only when the baby is very big, as in a diabetic mother or a physically
very small-built mother, or if the mother has had a fractured pelvis at some time.
Problems with Uterine Contraction: The uterine muscle may fail to contract properly
when it is grossly distended as in twin pregnancy and hydramnios (excess liquor amnii).
Presence of tumours like fibroids in the uterine musculature can also affect uterine
contraction.
Use of Sedatives and Anesthesia: Excessive use of painkillers or anesthesia can cause
inefficient uterine action. They can also decrease the pain of normal labour and prevent
voluntary effort by the mother to deliver the baby during the second stage of labor.
Cervical dystocia or stenosis: The term cervical dystocia is used when the cervix fails to
dilate properly and remains at the same position for more than 2 hours. The cervix may
fail to dilate when it is fibrosed due to previous operations like cone biopsy or due to the
presence of tumors like cervical polyps and fibroids.
Intact amniotic membranes: This is the common cause of the secondary arrest of the
previously normal labour; the intact bag of the membranes has an effect on the uterine
contractions. And the rupture of the membranes has been improving the progress of
labour
SIGNS AND SYMPTOMS OF PROLONGED LABOUR
Labor extends for more than 18 hours.
Patient looks exhausted and distressed. 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.
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.
The uterus is tender on palpation and does not relax fully between contractions.
Ketosis may develop due to prolonged starvation.
Fetal distress may develop.
Membranes may or may not rupture early. In early rupture, there is a risk of infection of
the uterine contents if proper antibiotics are not prescribed.
RISKS OF PROLONGED LABOUR
Fetal Risks:
o Fetal Distress due to decreased oxygen reaching the fetus.
o Intracranial hemorrhage or bleeding inside the fetal head.
o Increased chances of operative delivery like Caesarian sections.
o Long term risks of the baby developing cerebral palsy.
Maternal Risks:
o Intrauterine infections
o Trauma and injuries in the maternal birth passage
o Postpartum hemorrhage.
o Postpartum infection.
MANAGEMENT OF PROLONGED LABOUR
False labour
Examine for infections or ruptured membranes and then treat accordingly. If none of these are
present, you should discharge the woman and encourage her to return if signs of labour recur,
keeping her in the labour ward too long depresses women.
Protracted latent phase
If membranes are not ruptured, you can rupture the membranes, and induce labour using
oxytocin, and reassess the patient frequently, (4hrly), and if the patient has not entered the active
phase after 8 hours then deliver the baby by caesarean section.
If there are signs of infections, you augment labour immediately with oxytocin and give a
combination of antibiotics like Ampicillin I.V. 2g q6h and Gentamycin 5mg/kg body weight I.V
q24h. If the woman delivers vaginally you discontinue drugs postpartum but should be continued
if the mother delivers by caesarean section.
Prolonged active phase
When managing prolonged active stage of labour you need to consider the cause, maternal and
the fetal condition. And basically the management may require maternal resuscitation, rupture of
the amniotic membranes, augmentation and caesarean section.
Prolonged active expulsive phase
If malpresentation and obvious obstruction has been excluded and uterine contraction is strong,
and the descent is 1/5 you can do vacuum extraction or forceps delivery.
If the descent between 1/5 to 3/5 you should do vacuum and symphysiotomy but if the operator
is not proficient with symphysiotomy, you should do caesarean section
If the descent is more than 3/5, deliver by caesarean section.
