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

• Make a rapid evaluation of the condition of the woman and fetus and provide supportive care.

• Test urine for ketones and treat with IV fluids if ketotic.

• Review partograph.

DIAGNOSIS 

TABLE S-10

 Diagnosis of unsatisfactory progress of labour 

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:

• If there has been no change in cervical effacement or dilatation and there is no fetal distress, review the diagnosis. The woman may not be in labour.

• If there has been a change in cervical effacement or dilatation, rupture the membranes with an amniotic hook or a Kocher clamp and induce labour using oxytocin or prostaglandins:

- 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 there are no signs of cephalopelvic disproportion or obstruction and the membranes are intact, rupture the membranes with an amniotic hook or a Kocher clamp.

• Assess uterine contractions:

- 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).

• General methods of labour support may improve contractions and accelerate progress.

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.

• If cephalopelvic disproportion is confirmed (Table S-10), deliver by caesarean section.

• If the fetus is dead:

- 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. 

• Rupture the membranes with an amniotic hook or a Kocher clamp and augment labour using oxytocin.

• Reassess progress by vaginal examination 2 hours after a good contraction pattern with strong contractions has been established:

- 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 malpresentation and obvious obstruction have been excluded, augment labour with oxytocin. 

• If there is no descent after augmentation:

- 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.

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