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prolonged labor Obstetrics Labor of > 24 hrs duration, which may be due to a prolonged latent phase– > 20 hrs in a primigravida or > 14 hrs

in a multipara, or due to a 'protraction disorder' in which there is protracted cervical dilatation in the active phase of labor and protracted descent of the fetus. Written by : Dr.M.D.Mazumdar, MD 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. Causes of Prolonged Labor

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 then 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.

Early detection of abnormal progress of labour and the prevention of prolonged labour significantly reduce the risk of postpartum haemorrhage and sepsis.  . which may result in obstructed labour. uterine rupture and vesico-vaginal fistula. 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.  Use of Sedatives and Anesthesia: Excessive use of painkillers or anesthesia can cause inefficient uterine action.   Introduction Prolonged labour in the developing countries is commonly due to cephalopelvic disproportion (CPD). uterine rupture and thereby reduce the maternal mortality 1. 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. In countries where CPD is not prevalent. and eliminate obstructed labour. exhaustion. abnormal progress of labour is often due to 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. maternal dehydration.

The average length for mulitgravidas is 2. This prevents the baby from moving down into the birth canal. The rate of cervical dilation is 1.5 cm per hour. Most midwives realize that each woman's labor will be unique and that because of the many variables of each woman's labor and delivery. There are too many differences among women to hold fast to this graph in every situation.6 hours with an upper limit of 20 hours. Factors There are many different reasons that a labor may be prolonged.5 hours with an upper limit of 6 hours. with a maximum second stage of 2. * PROM. The maximum duration of the first stage of labor in primigravidas is 28. The average length of the latent phase in primigravidas is 8. The average length for multigravidas is 5. In multigravidas the maximum duration of first stage is 20 hours with a maximum second stage of 50 minutes. this graph must be used with common sense.Prolonged Labor Labor that lasts more than 24 hours is by definition called prolonged labor. At the end of the latent phase the cervix is dilated to about 3 cm.35 cm per hour.8 cm per hour. * Unripe cervix at the beginning of labor.5 hours. The best definition of the onset of labor is the time at which the woman has contractions that lead toward the birth of her baby. The exact time of the onset of labor is often hard to diagnose.8 hours with an upper limit of 12 hours. * Excessive analgesia * Primigravidity.5 hours. A prolonged latent phase does not mean that the active phase will also be prolonged. Weakness of uterine action is called hypotonic uterine dysfunction. Friedman's Graph Friedman made a graph to measure the progression of labor. The average length of the of the active phase in primigravidas is 5. * Malpresentations: Face or Brow Presentation Posterior Presentation * Inefficient uterine action and the inability of the cervix to dilate smoothly and rapidly. Cervical dilation averages 0. * Fetopelvic disproportion. .3 hours with an upper limit of 14 hours. According to Friedman's Graph: The latent phase of labor begins with the onset of labor and lasts until the beginning of the active phase of labor. The active phase begins at the end of the latent phase and lasts until full dilation of the cervix. First time mothers have longer labors. The rate of cervical dilation is at least 1. If a woman's membranes rupture before labor has begun it may take longer to establish an active labor pattern.2 to 6.

* The bladder is emptied every hour. * Vaginal exams are performed conservatively under sterile conditions. Management of Prolonged Labor * Encouragement is provided for the laboring woman. Prevention of Prolonged Labor * Good prenatal care reduces the incidence of prolonged labor. exhaustion. temperature.? * The uterine contractions are assessed for strength. * Labor is not induced or forced when the cervix is not ripe. The baby is closely monitored for signs of stress. frequency. This includes natural labor i inductions. Engagement and station should be noted. She will need extra support to get through a long labor. * The woman may eat and drink as desired during early labor. she should not wear herself out. * The condition of the baby is monitored by checking FHT's and watching for meconium. and changes. Assessment of Labor * The woman's progress is monitored and assessed regularly. efficiency. energy. the pelvis. injury. * False labor is treated by rest. Fetal wellbeing needs to be monitored.Risks Risks * Maternal risks include: uterine atony. The baby's position is checked for vertex presentation with good head flexion. Is it the cervix. If she knows she is in early labor. hemorrhage. * Fetal risks include: distress. * The woman's general condition is observed for signs of fatigue: hydration. weak uterine contractions. asphyxia. rupture of membranes. A tired uterus will not contract as efficiently. * The position of the baby and the presenting part must be accurately diagnosed. nourishment. the size of the head. * The woman should try to be well rested at the beginning of her labor. etc. and infection. Natural Remedies . * If there is failure of descent. interval. infection. the fetus. * Hydration is maintained. the cause needs to be determined. The urine is checked for ketones every 4 hours to make sure she is not showing signs of exhaustion. or drugs. and shock. pulse. * Pelvic adequacy and signs of CPD are assessed. length.

* Nipple stimulation releases natural oxytocin. * Positive. nonstressful environment will help the woman to move into a natural labor. comforting words will help her to relax.Many problems can be resolved by creating an atmosphere for the mother in which she feels comfortable and safe. of baking soda. This works best if both nipples are stimulated at the same time. Two hours later she should drink 2 . This concoction has a very high rate of success if the cervix is at least 2 cm dilated and 50% effaced. This will often help the baby's head to be better applied to the cervix and increase the strength and efficiency of contractions. The nipples should be massaged and pulled on in imitation of how a baby nurses. * Herbs: Oil of Primrose . The woman should eat a high carbohydrate meal. Dim lights or candles are very soothing. of orange juice and 1/2 tsp. * Bright lights can cause stress. * Castor Oil can be used if the woman is having a hard time moving into active labor. * A quiet. Emotional Aspects It is not uncommon to find an emotional reason that is stalling a woman's labor. * Try different positions to see which position works best for helping labor to progress. When the contraction is over massage begins again. . Studies have shown that animals who are scared or otherwise feel unsafe have dysfunctional labors.3 oz. If these emotional aspects can be addressed it will often resolve the dysfunctional labor.rubbed directly on the cervix encourages opening and softening of the cervix. * A warm bath or shower can help her to relax. of castor oil mixed with 6 oz. The nipples are massaged until a contraction starts and then massage is stopped. * Going for a walk may help. Putting women in water works very well.

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