Prolonged Labour
The term ‘prolonged labour’ is used when delivery does not take place after 12 hours of established labour
(Baird 1952, Myles 1999). Different terms are used for prolonged labour at different times or for different
reasons.
Prolonged Latent Stage
The latent phase lasts from the onset of labour to three centimetre dilatation of the cervical os. If this
phase takes more than 20 hours in a primigravida and more than14 hours in a multigravida, it is
considered prolonged. In practice diagnosis should be suspected and treatment instituted many hours
before this time interval has elapsed.
Prolonged second stage: -Primigravida – 2nd stage labour more than 2hrs multigravida – more
than 1hr
Primary Dysfunctional Labour
This is when active phase of labour is slow and the cervix dilates at less than one centimetre per hour.
Secondary Arrest
This is when there is slow cervical dilatation in the active phase after normal progress in early labour.
There are numerous causes of prolonged labour at each stage.
Causes of Prolonged First Stage of Labour (4 Ps)
Poor uterine contractions, leading to the cervix dilating slowly or not at all
Pelvic abnormalities (passage), where contracted pelvis and tumours of the pelvis cause poor
progress in labour
The foetus (passenger) is a large baby, or there is malposition or malpresentation, which prevent
the descent of the foetus, for example, occipito-posterior position or shoulder presentation
Psychological causes, for instance; tension and fear of the unknown tend to prolong labour, most
commonly in women who are primigravidae
Casues of Prolonged Second Stage of Labour
Secondary hypotonic contractions may cause a delay
Poor maternal effort, which could be due to fear, exhaustion or lack of sensation due to epidural
block, which may inhibit the woman’s ability to bear down
A rigid perineum, which may prevent the advance of the foetus. During the perineal phase, an
episiotomy should be performed at the height a contraction
Reduced pelvic outlet, as in the android pelvis, which narrows at the outlet due to its prominent
ischial spines and narrowed sub-pubic arch
A large foetus, malposition or malpresentation, leading to a large presenting diameter, accounting
for the delay
Remember: You should reassure the mother at all times during labour.
Diagnosis of Prolonged Labour
Now that you have seen the possible causes of prolonged labour, you will now focus on the diagnosis of
prolonged labour. The following methods may be used to diagnose prolonged labour:
Proper history of labour including type, duration and frequency of uterine contractions
Examination of the mother, checking for general appearance, whether distressed or
exhausted
Check the temperature and pulse as an increase of either of them would be significant
Urinalysis, where concentrated urine suggests fluid imbalance and dehydration. Check for ketones
in the urine, the presence of this must be corrected at once
It is important to identify the cause in order to decide the course of action.
Management of prolonged labour involves management as in normal labour but with some additional steps.
Additional Steps Required in the Management of Prolonged Labour
When progress of labour is delayed due to poor uterine contractions, syntocinon drip must be put
up. If there is no progress in spite of good uterine contraction, labour should be terminated by
caesarean section
Assist the mother to adopt a comfortable position
Start an intravenous infusion to correct dehydration and ketosis, for example, Ringer’s lactate
solution or 5% dextrose
Encourage the mother to empty her bladder every two hours and test the urine for ketones to
exclude maternal distress
Maintain a fluid input and output chart
Allow sips of water if absolutely necessary even in anticipation of
general anaesthesia
Give oral ranitidine (zantac) 15mg every six hours to reduce gastric secretions
Give broad-spectrum antibiotic if membranes rupture early (within 24 hours)
Observe and record every two to four hours temperature, pulse, respiration and blood pressure
Contractions should be recorded every 15 to 30 minutes and take care of the bladder every two
hours
Foetal Condition in Prolonged Labour
The following steps should be taken to monitor the foetal condition:
Monitor the foetal heart continuously every quarter to
half hour.
Observe the amniotic fluid for presence of meconium to rule out foetal distress.
For secondary hypotonic uterine contraction, commence an intravenous infusion of syntocinon with
10% dextrose to stimulate adequate contractions
Ensure that the presenting part is visible before encouraging the mother to push.
Perform an episiotomy under local anaesthesia or at the height of a contraction if the perineum is
rigid.
If the cause was obstruction at the outlet as in android pelvis, and the head is arrested mid pelvis
resulting to foetal distress, caesarean section is recommended.
Complications of Prolonged Labour
There are a number of complications, which may be experienced by both the mother and the foetus during
a prolonged labour.
Maternal complications
Oedema of the pelvic floor due to the pressure of the presenting part on the pelvic floor and the
vaginal walls
Retention of urine due to continuous compression of the urethra by the presenting part causing
bruising which might persist during puerperium
Ruptured uterus due to overstretching of the lower uterine segment
Deep perineal tears due to overstretching of the perineum, leading to cystocele or rectocele
The overstretching of the pelvic floor and uterine ligaments may also cause uterine prolapse
Stress incontinence
Foetal complications
Intra cranial damage due to excessive moulding
Foetal hypoxia, which will lead to asphyxia
Intra cranial haemorrhage due to prolonged compression of the head, and difficult
instrumental delivery
Prevention of Prolonged Labour
Good prenatal care is essential to prevent prolonged labour.
This includes:
Taking a proper history in relation to cases of previous difficult deliveries
Detection of malpresentation and malposition
Any sign of contracted pelvis should be referred to the obstetrician in time to make a timely decision
on the mode
of delivery
During labour you should take the following steps:
Maintain proper partograph of the mother in labour and take early decision
Ensure proper control of the syntocinon drip
Ensure bladder is emptied every two hours to avoid delay of labour
