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Department of Reproductive Health and Research (RHR), World Health Organization

Managing Complications in Pregnancy and Childbirth

A guide for midwives and doctors 

 


Section 2 - Symptoms


Unsatisfactory progress of labour

PROBLEMS

  • The latent phase is longer than 8 hours.

  • Cervical dilatation is to the right of the alert line on the partograph.

  • The woman has been experiencing labour pains for 12 hours or more without delivery (prolonged labour).

GENERAL MANAGEMENT

DIAGNOSIS 

TABLE S-10

 Diagnosis of unsatisfactory progress of labour 

Findings

Diagnosis

Cervix not dilated 

No palpable contractions/infrequent contractions

False labour

Cervix not dilated beyond 4 cm after 8 hours of regular contractions

Prolonged latent phase

Cervical dilatation to the right of the alert line on the partograph (Fig S-6)

• Secondary arrest of cervical dilatation and descent of presenting part in presence of good contractions

• Secondary arrest of cervical dilatation and descent of presenting part with large caput, third degree moulding, cervix poorly applied to presenting part, oedematous cervix, ballooning of lower uterine segment, formation of retraction band, maternal and fetal distress (Fig S-7)

• Less than three contractions in 10 minutes, each lasting less than 40 seconds (Fig S-8)

• Presentation other than vertex with occiput anterior

Prolonged active phase

Cephalopelvic disproportion

Obstruction


Inadequate uterine activity

Malpresentation or malposition

Cervix fully dilated and woman has urge to push, but there is no descent

Prolonged expulsive phase

 

Figure S-6  is a sample partograph for prolonged active phase of labour:

 

  • The woman was admitted in active labour at 10 AM:

- fetal head 5/5 palpable;

- cervix dilated 4 cm;

- inadequate contractions (two in 10 minutes, each lasting less than 20 seconds).

  • At 2 PM:

- fetal head still 5/5 palpable;

- cervix dilated 4 cm and to the right of the alert line;

- membranes ruptured spontaneously and amniotic fluid is clear;

- inadequate uterine contractions (one in 10 minutes, lasting less than 20 seconds). 

  • At 6 PM:

- fetal head still 5/5 palpable;

- cervix dilated 6 cm;

- contractions still inadequate (two in 10 minutes, each lasting less than 20 seconds).

  • At 9 PM:

- fetal heart rate 80 per minute;

- amniotic fluid stained with meconium;

- no further progress in labour. 

  • Caesarean section was performed at 9:20 PM due to fetal distress. 

  • Note that the partograph was not adequately filled out. The diagnosis of prolonged labour was evident at 2 PM and labour should have been augmented with oxytocin at that time.

FIGURE S-6 Partograph showing prolonged active phase of labour 

 

Figure S-7  is a sample partograph showing arrest of dilatation and descent in the active phase of labour. Fetal distress and third degree moulding together with arrest of dilatation and descent in the active phase of labour in the presence of adequate uterine contractions indicates obstructed labour.

  • The woman was admitted in active labour at 10 AM:

- fetal head 3/5 palpable;

- cervix dilated 4 cm;

- three contractions in 10 minutes, each lasting 20–40 seconds;

- clear amniotic fluid draining;

- first degree moulding.

  • At 2 PM:

- fetal head still 3/5 palpable;

- cervix dilated 6 cm and to the right of the alert line;

ght improvement in contractions (three in 10 minutes, each lasting 40 seconds);

- second degree moulding.

  • At 5 PM:

- fetal head still 3/5 palpable;

- cervix still dilated 6 cm;

- third degree moulding;

- fetal heart rate 92 per minute.

  • Caesarean section was performed at 5:30 PM.

FIGURE S-7 Partograph showing obstructed labour 

 

Figure S-8 is a sample partograph for poor progress of labour due to inadequate uterine contractions corrected with oxytocin.

  • The woman was admitted in active labour at 10 AM:

- fetal head 5/5 palpable;

- cervix dilated 4 cm;

- two contractions in 10 minutes, each lasting less than 20 seconds. 

  • At 12 PM:

- fetal head still 5/5 palpable;

- cervix still dilated 4 cm and to the right of the alert line;

- no improvement in contractions.

  • At 2 PM:

- poor progress of labour due to inefficient uterine contractions diagnosed;

- augmented labour with oxytocin 10 units in 1 L IV fluids at 15 drops per minute;

- escalated oxytocin until a good pattern of contractions was established;

- contractions improved and were accompanied by descent of the presenting part and progressive cervical dilatation.

  • Spontaneous vaginal delivery occurred at 8 PM.

FIGURE S-8 Partograph showing inadequate uterine contractions corrected with oxytocin 

 

MANAGEMENT

FALSE LABOUR

Examine for urinary tract or other infection (Table S-13) or ruptured membranes and treat accordingly. If none of these are present, discharge the woman and encourage her to return if signs of labour recur.

PROLONGED LATENT PHASE

The diagnosis of prolonged latent phase is made retrospectively. When contractions cease, the woman is said to have had false labour. When contractions become regular and dilatation progresses beyond 4 cm, the woman is said to have been in the latent phase.

Misdiagnosing false labour or prolonged latent phase leads to unnecessary induction or augmentation, which may fail. This may lead to unnecessary caesarean section and amnionitis. 

If a woman has been in the latent phase for more than 8 hours and there is little sign of progress, reassess the situation by assessing the cervix:

- Reassess every 4 hours;

- If the woman has not entered the active phase after 8 hours of oxytocin infusion, deliver by caesarean section.

  • If there are signs of infection (fever, foul-smelling vaginal discharge):

- Augment labour immediately with oxytocin;

- Give a combination of antibiotics until delivery:

- ampicillin 2 g IV every 6 hours;

- PLUS gentamicin 5 mg/kg body weight IV every 24 hours;

- If the woman delivers vaginally, discontinue antibiotics postpartum;

- If the woman has a caesarean section, continue antibiotics PLUS give metronidazole 500 mg IV every 8 hours until the woman is fever-free for 48 hours.

PROLONGED ACTIVE PHASE

- If contractions are inefficient (less than three contractions in 10 minutes, each lasting less than 40 seconds), suspect inadequate uterine activity (page S-66);

- If contractions are efficient (three contractions in 10 minutes, each lasting more than 40 seconds) suspect cephalopelvic disproportion, obstruction, malposition or
malpresentation (see below).

CEPHALOPELVIC DISPROPORTION

Cephalopelvic disproportion occurs because the fetus is too large or the maternal pelvis is too small.  If labour persists with cephalopelvic disproportion, it may become arrested or obstructed. The best test to determine if a pelvis is adequate is a trial of labour. Clinical pelvimetry is of limited value.

- Deliver by craniotomy;

- If the operator is not proficient in craniotomy, deliver by ccaesarean section.

OBSTRUCTION

Note: Rupture of an unscarred uterus is usually caused by obstructed labour.

  • If the fetus is alive, the cervix is fully dilated and the head is at 0 station or below, deliver by vacuum extraction;

  • If there is an indication for vacuum extraction and symphysiotomy for relative obstruction and the fetal head is at -2 station:

- Deliver by vacuum extraction and symphysiotomy;

- If the operator is not proficient in symphysiotomy, deliver by caesarean section.

  • If the fetus is alive but the cervix is not fully dilated or if the fetal head is too high for vacuum extraction, deliver by caesarean section.

  • If the fetus is dead:

- Deliver by craniotomy;

- If the operator is not proficient in craniotomy, deliver by caesarean section.

INADEQUATE UTERINE ACTIVITY

If contractions are inefficient and cephalopelvic disproportion and obstruction have been excluded, the most probable cause of prolonged labour is inadequate uterine activity.

Inefficient contractions are less common in a multigravida than in a primigravida. Hence, every effort should be made to rule out disproportion in a multigravida before augmenting with oxytocin. 

- If there is no progress between examinations, deliver by caesarean section;

- If progress continues, continue oxytocin infusion and re-examine after 2 hours. Continue to follow progress carefully.

 

PROLONGED EXPULSIVE PHASE

Maternal expulsive efforts increase fetal risk by reducing the delivery of oxygen to the placenta. Allow spontaneous maternal “pushing”, but do not encourage prolonged effort and holding the breath.

- If the head is not more than 1/5 above the symphysis pubis or the leading bony edge of the fetal head is at 0 station, deliver by vacuum extraction or forceps;

- If the head is between 1/5 and 3/5 above the symphysis pubis or the leading bony edge of the fetal head is between 0 station and -2 station:

- Deliver by vacuum extraction and symphysiotomy;

- If the operator is not proficient in symphysiotomy, deliver by caesarean section.

- If the head is more than 3/5 above the symphysis pubis or the leading bony edge of the fetal head is above -2 station, deliver by caesarean section.

Top of page

 

Clinical principles

Rapid initial assessment

Talking with women and their families

Emotional and psychological support

Emergencies

General care principles

Clinical use of blood, blood products and replacement fluids

Antibiotic therapy

Anaesthesia and analgesia

Operative care principles

Normal Labour and childbirth

Newborn care principles

Provider and community linkages

Symptoms

Shock

Vaginal bleeding in early pregnancy

Vaginal bleeding in later pregnancy and labour

Vaginal bleeding after childbirth

Headache, blurred vision, convulsions or loss of consciousness, elevated blood pressure

Unsatisfactory progress of Labour

Malpositions and malpresentations

Shoulder dystocia

Labour with an overdistended uterus

Labour with a scarred uterus

Fetal distress in Labour

Prolapsed cord

Fever during pregnancy and labour

Fever after childbirth

Abdominal pain in early pregnancy

Abdominal pain in later pregnancy and after childbirth

Difficulty in breathing

Loss of fetal movements

Prelabour rupture of membranes

Immediate newborn conditions or problems

Procedures

Paracervical block

Pudendal block

Local anaesthesia for caesaran section

Spinal (subarachnoid) anaesthesia

Ketamine

External version

Induction and augmentation of labour

Vacuum extraction

Forceps delivery

Caesarean section

Symphysontomy

Craniotomy and craniocentesis

Dilatation and curettage

Manual vacuum aspiration

Culdocentesis and colpotomy

Episiotomy

Manual removal of placenta

Repair of cervical tears

Repair of vaginal and perinetal tears

Correcting uterine inversion

Repair of ruptured uterus

Uterine and utero-ovarian artery ligation

Postpartum hysterectomy

Salpingectomy for ectopic pregnancuy

Appendix

 

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