Prolonged Labor
 

Prolonged Labor Notes © Gail Hart

Definitions -- average labor primips - 20 hours of first stage and 2 hours of second stage , multips - 14 hours of first stage and 1 hour of second stage. (Freidman’s curve)

 

 

Risks of prolonged labor

There are risks outside of anesthetic effects: infection, maternal exhaustion, postpartum hemorrhage and fetal distress.

 

Risk of infection is increased by:

  • early Rupture Of Membranes.

  • numerous internals to assess progress

  • cervical manipulation or massage

  • invasive gadgetry (internal monitors, tubes, catherization etc. Internal monitor is risk for strep)


Maternal exhaustion; risk increased by

  • efforts to stimulate labor -- pitocin, herbs/walking/drugs -- which tire the woman

  • withholding food or liquids – a still common practice in some institutions.

  • dehydration due to NPO rules or vomiting

  • pitocin; causing stronger than normal contractions –with increased pain and increased need for pain medications

  • lack of sleep


Fetal distress; risk increased by;

  • pitocin,

  • Artificial Rupture of Membranes

  • maternal low bloodsugar due to withholding food and fluids

  • maternal supine position (hypotensive syndrome)

  • effects of anesthetics

  • coached pushing acidosis

  • vacuum extraction, forceps, etc.

 

 

Postpartum hemorrhage risk increased by;

  • maternal exhaustion

  • dehydration from withholding foods and fluids

  • pitocin or herbs to stimulate labor

  • efforts to speed second stage – forced (coached) pushing, mcRobert’s position, vacuum, forceps, or fundal pressure


Four reasons for prolonged labor:

  • Mis-interpretation of false or latent-phase labor.

  • Prolonged latent phase (a variation of normal pattern)

  • Weak or erratic contractions, poor pattern or lack of pattern (may have either a mechanical or emotional cause)

  • Malpresentation, or malposition causing poor pattern or tight fit.

  • Truly a tight fit – Cephalo-Pelvic Disproportion



FIRST THINGS: DIAGNOSIS OF TRUE LABOR!

Don’t “start the clock” before it is time!

  • False labor -- weak, erratic contractions, poor pattern, varying in both length and in intensity. . They do not grow progressively stronger and longer They are usually under one minute long -- and peak at under 45 seconds.

  • Latent phase -- contractions with or without effacement, but with little or no dilation. Often irregular and with a poor pattern. .


A long latent phase – up to 20 hours -- is very normal for a first-time motheri. It’s the effacement phase of labor. A multip might not enter active phase until she is quite well dilated, and a grandmultip may still be in latent labor until she reaches 7 centimeters! iiiiiiv STIMULATING LATENT PHASE LABOR IS AN INDUCTION OF LABOR - AND CARRIES THE USUAL RISKS OF INDUCTION (increased rates of cesarean sectionand assisted delivery, prolonged active phase, increased pain medication)v. The cure for prolonged latent phase labor is either “tincture of time”, or medicated rest.


True labor” contractions usually last over one minute, the abdomen is very firm during contractions (not indentable), and there is usually some degree of digestive or intestinal upset – although excitement may trigger stomach symptoms even if a woman is not in true labor. The cervix effaces and dilates, and dilation is sustained even if contractions wane.

General Tips

  • Empty the house! Send visitors home (try to avoid rushing about)

  • Advise food, liquids, and normal living patterns. Do daytime things in the daytime, and sleep at night.

  • hydration is important, but use moderation. Don't over-hydrate or overfill the bladder. Aim for 6 to 8 ounces per hour. Offer water, broth or soup, sweet drinks, or juice to give sugar.

  • Food! She should be allowed to eat anything she can eat!

  • Distraction. Do not time contractions in the early phases.


PATIENCE: Time will usually cure prolonged latent phase.

  • Therapeutic Rest. Sometimes sleep is the cure for both prolonged latent phase and inefficient labor. In hospital morphine or other anesthetics may be used. When the woman awakens she’ll often begin active labor, or else find that the inefficient contractions have stopped. (With morphine sleep, appx 85% of women will wake in active labor, while about 10% will cease to have contractions, few will remain in inefficient labor) vi Home based midwives find similar response rates to home rest treatments. REST IS THE CURE!


AVOID CAUSING PROBLEMS: Lower the risk of problems!

  • Avoid vaginal exams – or sharply limit them -- unless the contraction pattern has improved for a long time.

  • Push fluids. Increased fluids can create stronger contractions!vii

  • But… make sure mom keeps her bladder empty!

  • Keep membranes intact. Don’t break the waters unless definitely indicated. -Intact membranes protect the baby from infection and the stress of labor.

  • Watch FHT appropriately..

  • Correct malpositions early, if possible, to avoid impaction.

  • Avoid maternal exhaustion-- keep mom hydrated, rested, fed etc

  • Avoid anxiety and fear. Foster reassurance and hope.


INTERVENTIONS: home methods to stimulate or augment labor.

Prolonged labor due to weak or short or erratic contractions.

Strengthen contractions:

  • improve baby’s position.

  • maternal activity - walking

  • Sweet drinks, (old cure: a spoon of honey followed by sips of water or tea!)

  • Hydration – even “over-hydration” – may strengthen contractions.viii

  • Hydrotherapy -- Deep warm baths or long showers, or jacuzzi-type tub.

  • Empty bowel with castor oil, or an enema to trigger a reflex stimulus. Consider an herbal enema. (remember, this is an INTERVENTION and should not  be done routinely)

  • Abdominal massage.

  • Belly lifts or an abdominal wrap

  • Cervical massage/stretch.

  • Maternal position changes – – Side-lying, lunge, squat, toilet sitting, tailor sitting; McRoberts (in second stage), hands and knees.

  • Pattern of alternating positions; from sidelying to standing; squatting to hands and knees; tubbing to toilet sitting. “pattern of threes”

  • AROM – . It “sets the clock ticking” and increases the risk of neonatal sepsis. ROM also increases the force of contractions on the baby, and it might raise the risk of fetal distress and of cord prolapse. But… sometimes it does the job.


Prolonged Second stage

Normal to be slow if contractions are strong but widely spaced

  • food or drink, or a glucose IV. Traditional advice: “Feed the uterus to strengthen contractions” – feed the mother to feed the uterus!

  • Position changes. Standing, the lunge position, hands and knees, walking, toilet sitting (a favorite midwife trick!), backward toilet sitting, true squat GET OUT OF BED!

  • Malpositions: may need to be corrected, or might just take extra time for rotation. Evaluate carefully!

  • Avoid fetal distress by avoiding the stress of coached pushing.

  • Physiologic pushing – or no pushing – will rest both mom and baby and may help the baby align better as he descends. Babies born after physiologic pushing have higher apgars and less acidosis and lower risk of fetal distress or need for resuscitation! (see reff 8)

  • Rest! Resting may be the perfect cure for a slow second stage descent.

"Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial. Hansen SL, Clark SL, Foster JC

When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups. CONCLUSION: Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit. "(reff 8) (Obstet Gynecol 2002 Jan;99(1):29-34



Monitor mother and baby carefully for signs of:


  • Infection – fever, increasing maternal pulse

  • Fetal distress – “tired” fhts (especially deceleration patterns) fresh meconium. The normal fetal movements should continue. Normal movements indicate good condition),

  • Exhaustion – True maternal exhaustion, with rising pulse and temperature, hot skin, dehydration, vomiting, ketosis.


Monitor progress and descent

  • There must be progress – even if slight – and mom and baby must remain in good condition.

  • Detect descent abdominally if possible to avoid internals

There is no arbitrary limit to prolonged labor – as long as progress continues and as long as mom and baby are in good condition (see ix x), but know when to quit

Remember these signs of obstruction, and signs of potential uterine rupture.

  • Hot, dry, swollen vagina.

  • No descent in spite of strong contractions – or descent only with extreme flexion.

  • Caput growing, sutures over-riding.

  • A thinning lower uterine segment.

  • Rising contraction ring.

  • Formation of Bandl’s Ring.


Don’t EVER take things this far! Be Prudent! Get help! Rule-out obstructed labor within a reasonable time period!


A prolonged labor might also be a symptom of obstructed labor !

Signs of possible disproportion:

  • High head

  • Asynclitism,

  • Strong contractions without progress of dilation.

  • failure of flexion and descent with strong contractions

  • large and growing caput, but with no descent as felt above pubic bone


ASSESSING FOR DISPROPORTION

Is the head engaged? ( Don’t confuse station with engagement).

Use “fifths”. The head is free above the brim – or “five out of five” – 5/5. It will not have entered the pelvis – or be engaged – until more than half (or three-fifths), has sunk below the top of the pubic bone.

 

 

Most primiparas are engaged late in pregnancy or by early labor. Mulitps often not until late in labor.

Test for engagement” during combined internal/external maneuvers.

  • Munro-Kerr for descent, or over-riding

  • Standing Test for Engagement.


Cochrane’s The Guide to Effective Care in Pregnancy and Childbirth says this well: “If the mother’s condition is satisfactory, the baby’s condition is satisfactory and there is evidence that progress is occurring with descent of the presenting part, there are no grounds for intervention. “If the mother is not unduly distressed and is not actively pushing (particularly when she has epidural analgesia) there is no reason to think that the second stage is any more likely to cause exhaustion than the first stage”.


© Gail Hart

i ibid

ii Am J Obstet Gynecol 2002 Jun;186(6):1331-8
The labor curve of the grand multipara: does progress of labor continue to improve with additional childbearing?
Gurewitsch ED, Diament P, Fong J, Huang GH, Popovtzer A, Weinstein D, Chervenak FA.
Pregnancies in 1095 GMs, 1174 lower-parity multiparous women, and 908 nulliparous women were studied. GMs exhibit a longer initial phase of labor than either nulliparous women or lower-parity multiparous women, begin to dilate rapidly at a greater dilatation than nulliparous women, and experience acceleration of labor at a rate no faster than lower-parity multiparous women. … Once parity exceeds 4, progress of labor slows. "Poor progress" beyond dilatation of 4 cm should not be considered abnormal for a GM, because she is likely still in the latent phase until dilatation of 6 cm is attained. ..PMID: 12066118

iii

iv

v

Am J Obstet Gynecol 1999 Mar;180(3 Pt 1):628-33Induction of labor and the relationship to cesarean delivery: A review of 7001 consecutive inductions.

vi OBSTETRICS: Gabbe, Niebyl, Simpson; pg 137

vii Am J Obstet Gynecol 2000 Dec;183(6):1544-8

A randomized controlled trial of the effect of increased intravenous hydration on the course of labor in nulliparous women. Garite TJ, Weeks J, Peters-Phair K, Pattillo C, Brewster WR

One hundred ninety-five primiparous patients were randomly selected receive either 125 mL or 250 mL of intravenous fluids per hour. The frequency of labor lasting >12 hours was statistically higher in the 125-mL group (20/78 [26%] vs 12/91 [13%]; P =.047). In addition, there was a trend favoring longer mean duration of the first stage and total duration of labor in patients delivered vaginally in the 125-mL group, by 70 and 68 minutes, respectively (P

=.06). There was a trend toward a lower frequency of oxytocin administration for inadequate labor progress in the higher fluid rate group (61 [65%] in the 125-mL group vs 51 [49%] in the 250-mL group; P =.06). Cesarean deliveries were more frequent in the 125-mL group (n = 16) than in the 250-mL group (n = 10) but did not reach statistical significance.

CONCLUSION: This study presents the novel finding that increasing fluid administration for nulliparous women in labor above rates commonly used is associated with a lower frequency of prolonged labor and possibly less need for oxytocin. Thus inadequate hydration in labor

may be a factor contributing to dysfunctional labor and possibly cesarean delivery. PMID: 11120525


viii See Garite study.


ix Am j obstetri gynecol 1995 sep;173(3 pt 1):906-12

Perinatal outcome in relation to second-stage duration.

Menticoglou SM, Manning F, Harman C, Morrison I.

. STUDY DESIGN: Over a 5-year period at one university teaching hospital, 6041 nulliparous women reached the second stage of labor with a live singleton cephalic fetus with birth weight > or = 2500 gm. A retrospective review of perinatal morbidity and mortality was performed and the results related to the duration of the second stage. RESULTS: The second stage lasted > 3 hours in 11% of nulliparous women and > 5 hours in 2.7%. There were no perinatals death unrelated to anomaly. There was no significant relationship between second-stage duration and low 5-minute Apgar score, neonatal seizures, or admission to the neonatal intensive care unit. CONCLUSION: Operative intervention in the second stage is not warranted merely because some set number of hours has elapsed. PMID: 7573267


: J Reprod Med 1990 Mar;35(3):229-31

Perinatal outcome after a prolonged second stage of labor.

Moon JM, Smith CV, Rayburn WF.

It is commonly held that the second stage of labor should last no more than two hours because of an apparently increased risk of morbidity. The purpose of this investigation was to determine whether this commonly held notion is true in this era of close fetal monitoring and umbilical blood gas determination. Between May 1987 and October 1988, 50 (3.5%) of 1,432 uncomplicated term pregnancies ended in delivery after a second stage of labor lasting greater than 120 minutes. A prolonged second stage was associated more commonly with nulliparity, occiput posterior positioning, epidural anesthesia and a need for operative delivery but not birth weight greater than 4,000 g or a short umbilical cord. Infants born after a prolonged second stage did not have an increased incidence of umbilical artery pH less than 7.20 or of five-minute Apgar scores less than 7, nor did they need intensive care nursery admission. A prolonged second stage of labor appears not to impose an increased risk.


x Obstet Gynecol 2002 Jan;99(1):29-34

Active pushing versus passive fetal descent in the second stage of labor: a randomized controlled trial.
Hansen SL, Clark SL, Foster JC.

OBJECTIVE: To compare perinatal outcomes among women with epidural anesthesia who were encouraged to push at complete dilatation with those who had a period of rest before pushing began. METHODS: After a power analysis to determine appropriate sample size (based upon an alpha error rate of.05% and 80% power), a prospective randomized trial of 252 women with epidural anesthesia was conducted. Patients were randomized to a rest period or immediate pushing at complete dilatation. Variables measured included rate of fetal descent, length of time of pushing, the number and type of fetal heart rate decelerations, Apgar scores, arterial cord pH values, perineal injuries, type of delivery, length of second stage, maternal fatigue, and endometritis. RESULTS: When a period of rest was used before pushing, we found a longer second stage, decreased pushing time, fewer decelerations, and, in primiparous women, less fatigue compared with control patients. Apgar scores, arterial cord pH values, rates of perineal injury, instrument delivery, and endometritis were similar in both groups. CONCLUSION: Delayed pushing was not associated with demonstrable adverse outcome, despite second-stage length of up to 4.9 hours. In select patients, such delay may be of benefit. PMID: 11777506

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