Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Emergency Obstectric Care
Hypertension in Pregnancy
Hypertension
Assessment and management
Delivery
Postpartum care
Chronic hypertension
Complications
Management of Slow Progress of Labour
General principles
Slow progress of labour
Progress of labour
Operative procedures
Bleeding in Pregnancy and Childbirth
Bleeding
Diagnosis and initial management
Specific management
Procedures
Aftercare and follow-up
Progress of Labour
 




Slow progress of labour associated with prolonged active phase


The diagnosis of a prolonged latent phase is made retrospectively:

:: When contractions cease, diagnose as false labour
:: When contractions become regular and dilatation progresses beyond 4 cm, diagnose as latent phase.


Mistaking false labour for the latent phase leads to unnecessary induction and unnecessary caesarean section.


The latent phase is prolonged when the cervical dilatation remains less than 4 cm after 8 hours. If a woman has been in the latent phase for more than 8 hours, reassess the situation:

:: If there has been no change in cervical effacement or dilatation and there is no fetal distress, review the diagnosis of labour; the woman may not be in labour
:: If there has been a change in cervical effacement and dilatation, augment contractions with oxytocin. Artificial rupture of membranes is recommended along with or before augmentation of labour with oxytocin. In areas of high HIV prevalence, however, if elective caesarean section is not the preferred option, try to leave the membranes intact for as long as possible to reduce the risk of transmission of HIV.


Reassess every 4 hours:

:: If the woman has not entered the active phase within 8 hours, consider delivery by caesarean section, but be sure the patient is not in false labour
:: If membranes are already spontaneously ruptured, induce or augment labour without delay
:: In areas of high Group B streptococcal prevalence, give antibiotic prophylaxis starting at 12 hours after rupture of the membranes to help reduce Group B streptococcus infection in the neonate
:: If there is any evidence of amnionitis, augment labour immediately and treat with antibiotics.


Slow progress of labour associated with Prolonged Active Phase

During active labour, dilatation usually progresses at least 1 cm per hour. Any rate of dilatation slower than this indicates a slow active phase. If the slow active phase is neglected, it can lead to a prolonged active phase. Slow progress of labour in the active phase of labour may be due to one or more of the following causes:

:: Inefficient uterine contractions
:: Malpresentations and malpositions: e.g. occipito-posterior
:: Disproportion between the size of the fetus and the pelvis.

These causes may be interrelated. When the rate of dilatation in the active phase is slower than 1 cm per hour, reassess the mother for poor contractions or malpresentation:

:: If there is evidence of obstruction, perform a caesarean section
:: If there is no evidence of obstruction, augment labour with amniotomy and oxytocin.

General methods of labour support may improve contractions and accelerate progress:

:: Provide emotional support and encouragement
:: Encourage walking, sitting and changes of position
:: Give abundant fluids either by mouth or IV
:: Encourage urination
:: Catheterize only as a last resort.

Reassess progress by vaginal examination after 2 hours of good contractions:

:: If there is no progress between examinations, deliver by caesarean section
:: If there is progress, continue oxytocin and re-examine after 2 hours.

Continue to follow progress carefully.

Inefficient, poor uterine contractions are less common in a multigravida, so make every effort to rule out disproportion before augmenting with oxytocin.

In the active phase of labour, plotting of cervical dilatation will normally remain on, or to the left of the alert line on the partograph. The action line is 4 hours to the right of the alert line. If a woman’s labour reaches this line, you will need to make a decision about the cause of the slow progress and take appropriate action.

Slow progress of labour associated with Prolonged Expulsive Phase


The effective force during delivery of the fetus comes from uterine contractions. Spontaneous maternal “pushing” should be permitted, but the practice of encouraging breath-holding and prolonged effort should be abandoned.

Prolongation of the expulsive phase may also occur for the same reasons as prolongation of the active phase. If malpresentation and obvious obstruction have been excluded, failure of descent in the expulsive stage should also be treated by oxytocin infusion unless contraindicated. If there is no descent even after augmentation with oxytocin, consider assisted delivery.

Assisted vaginal delivery by forceps or ventouse is indicated if the head is engaged (not more than 1/5 of the head is palpable above the pelvic brim) or if the leading bony edge of the fetal head is at 1 cm or more below the level of the ischial spines by vaginal examination.

Caesarean delivery is the preferred option if the head is at a higher level.


Slow progress of Labour associated with Malpositions and Malpresentations

Occipito-posterior positions


Spontaneous rotation to the anterior position occurs in 90% of cases. Spontaneous delivery in the posterior position may occur, but labour may be complicated by prolonged first and second stages. Perineal tears and extensions of an episiotomy may complicate delivery.

Arrested labour


Arrested labour may occur when rotation and/or descent of the head does not occur:

:: Ensure adequate hydration
:: Check maternal and fetal condition
  If there is fetal distress, consider delivery by caesarean section if quick and easy vaginal delivery is not possible
:: If there is still no descent after a trial of labour and the head is engaged and at 1 cm or more below the ischial spines, deliver by forceps or ventouse
:: If the head is >1/5 palpable on abdominal examination, deliver by caesarean section
:: If there is evidence of obstruction or fetal distress at any stage, deliver by caesarean section.

Brow presentation

Spontaneous conversion to either vertex or face presentation may occur, particularly when the fetus is small or when there is fetal death with maceration. It is unusual for spontaneous conversion to occur in an average sized live baby once membranes have ruptured. Arrested labour is usual.

When the fetus is living:

:: Deliver by caesarean section.


When the fetus is dead:

:: If dilatation is incomplete, deliver by caesarean section
:: If dilatation is complete, perform craniotomy or caesarean section.


Do not deliver brow presentation by vacuum extraction, forceps or symphysiotomy.


Face presentation


Prolonged labour is common with face presentation:

:: In the chin-anterior position, descent and delivery of the head by flexion may occur
:: In the chin-posterior position, the fully extended head is blocked by the sacrum from descent and arrest of labour occurs.


Face presentation, chin anterior, can usually be delivered vaginally. Chin posterior can rarely be delivered vaginally.

:: Ensure adequate hydration
:: Check maternal and fetal condition
  If there is fetal distress, consider delivery by caesarean section if quick and easy vaginal delivery is not possible
:: If the cervix is not fully dilated and it is a chin-anterior position and there is no evidence of obstruction, augment with oxytocin; review progress as with vertex presentation
:: If it is a chin-posterior position or there is evidence of obstruction, deliver by caesarean section
:: If the cervix is fully dilated and it is a chin anterior and there is no evidence of obstruction, augment with oxytocin; if descent is satisfactory, deliver by forceps
:: If descent is unsatisfactory, deliver by caesarean section
:: If the fetus is dead, perform craniotomy or caesarean section.


Do not perform vacuum extraction for face presentation.


Compound presentation (arm prolapsed alongside presenting part)

Spontaneous delivery can occur only when the fetus is very small or dead and macerated. Arrested labour in the expulsive stage is the rule. Replacement of the prolapsed arm is sometimes possible.

:: Place the patient in the knee-chest position. Push the arm above the pelvic brim and hold it there until a contraction pushes the head into the pelvis.
:: Cord prolapse is a risk of this procedure, so be prepared to perform a caesarean section.



Breech presentation


Prolonged labour is an indication for urgent caesarean section in breech presentation (Figures 11.6, 11.7, 11.8). Failure of labour to progress is a sign of possible disproportion.

Figure 11.6
Figure 11.6



Figure 11.7
Figure 11.7



Figure 11.8
Figure 11.8


Transverse lie


Caesarean section is the management of choice, whether the fetus is alive or dead (Figure 11.9).


Figure 11.9
Figure 11.9


Delivery through a transverse uterine incision may be difficult, especially if the arm is prolapsed or the fetus is back-down, and often results in extension of the incision with laceration of a uterine artery.



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