prolonged labor Obstetrics Labor of > 24 hrs duration, which may be due to a prolonged latent phase > 20 hrs

in a primigravida or > 14 hrs in a multipara, or due to a 'protraction disorder' in which there is protracted cervical dilatation in the active phase of labor and protracted descent of the fetus. Written by : Dr.M.D.Mazumdar, MD Labor is said to be prolonged when the combined duration of both the first stage and second stages of labor is more than 18 hours. It is more common in a first pregnancy and in women over the age of 35 years. Causes of Prolonged Labor

Malpresentations: The normal position of the fetus is longitudinal with the fetal spine parallel to the mother's spine. The fetus lies in a completely flexed position with the chin touching the chest and the arms and legs flexed in front. The fetus normally faces the mother's back for a smooth delivery. Any change in this position can cause prolongation in the duration in labor. A breech presentation in which the fetus is in the buttocks down position, a face presentation in which the fetus faces the mother's abdomen, or a deflexed position of the head in which the neck of the fetus is less flexed or even straight or extended can all cause prolonged labor.

Cephalopelvic Disproportion (CPD) CPD is said to occur when the size of the fetal head is bigger then the size of the maternal pelvic passage or birth canal. In most pregnant women in labor, ligaments and joints tend to become more flexible, enabling them to relax more at the time of labor. The baby's skull bones are also capable of overlapping each other normally to some extent, decreasing the size of the head('moulding'. So, it is difficult to estimate by physical examination alone if CPD is actually present. But if labor is unduly prolonged and no other cause is detected, a diagnosis of CPD is usually made. True CPD occurs only when the baby is very big, as in a diabetic mother or a physically very small-built mother, or if the mother has had a fractured pelvis at some time.

Problems with Uterine Contraction: The uterine muscle may fail to contract properly when it is grossly distended as in twin pregnancy and hydramnios (excess liquor amnii). Presence of tumours like fibroids in the uterine musculature can also affect uterine contraction.

Use of Sedatives and Anesthesia: Excessive use of painkillers or anesthesia can cause inefficient uterine action. They can also decrease the pain of normal labour and prevent voluntary effort by the mother to deliver the baby during the second stage of labor. Cervical dystocia or stenosis: The term cervical dystocia is used when the cervix fails to dilate properly and remains at the same position for more than 2 hours. The cervix may fail to dilate when it is fibrosed due to previous operations like cone biopsy or due to the presence of tumors like cervical polyps and fibroids.

Introduction
Prolonged labour in the developing countries is commonly due to cephalopelvic disproportion (CPD), which may result in obstructed labour, maternal dehydration, exhaustion, uterine rupture and vesico-vaginal fistula. In countries where CPD is not prevalent, abnormal progress of labour is often due to inefficient uterine action. Early detection of abnormal progress of labour and the prevention of prolonged labour significantly reduce the risk of postpartum haemorrhage and sepsis, and eliminate obstructed labour, uterine rupture and thereby reduce the maternal mortality 1.

Prolonged Labor Labor that lasts more than 24 hours is by definition called prolonged labor. The exact time of the onset of labor is often hard to diagnose. The best definition of the onset of labor is the time at which the woman has contractions that lead toward the birth of her baby. Friedman's Graph Friedman made a graph to measure the progression of labor. Most midwives realize that each woman's labor will be unique and that because of the many variables of each woman's labor and delivery, this graph must be used with common sense. There are too many differences among women to hold fast to this graph in every situation. According to Friedman's Graph: The latent phase of labor begins with the onset of labor and lasts until the beginning of the active phase of labor. Cervical dilation averages 0.35 cm per hour. At the end of the latent phase the cervix is dilated to about 3 cm. The average length of the latent phase in primigravidas is 8.6 hours with an upper limit of 20 hours. The average length for multigravidas is 5.3 hours with an upper limit of 14 hours. A prolonged latent phase does not mean that the active phase will also be prolonged. The active phase begins at the end of the latent phase and lasts until full dilation of the cervix. The average length of the of the active phase in primigravidas is 5.8 hours with an upper limit of 12 hours. The rate of cervical dilation is 1.2 to 6.8 cm per hour. The average length for mulitgravidas is 2.5 hours with an upper limit of 6 hours. The rate of cervical dilation is at least 1.5 cm per hour. The maximum duration of the first stage of labor in primigravidas is 28.5 hours, with a maximum second stage of 2.5 hours. In multigravidas the maximum duration of first stage is 20 hours with a maximum second stage of 50 minutes. Factors There are many different reasons that a labor may be prolonged. * Fetopelvic disproportion. This prevents the baby from moving down into the birth canal. * Malpresentations: Face or Brow Presentation Posterior Presentation * Inefficient uterine action and the inability of the cervix to dilate smoothly and rapidly. Weakness of uterine action is called hypotonic uterine dysfunction. * Excessive analgesia * Primigravidity. First time mothers have longer labors. * PROM. If a woman's membranes rupture before labor has begun it may take longer to establish an active labor pattern. * Unripe cervix at the beginning of labor.

Risks Risks * Maternal risks include: uterine atony, hemorrhage, infection, exhaustion, and shock. * Fetal risks include: distress, asphyxia, injury, and infection. Fetal wellbeing needs to be monitored. Prevention of Prolonged Labor * Good prenatal care reduces the incidence of prolonged labor. The baby's position is checked for vertex presentation with good head flexion. * False labor is treated by rest. * Labor is not induced or forced when the cervix is not ripe. This includes natural labor i inductions, rupture of membranes, or drugs. * The woman should try to be well rested at the beginning of her labor. If she knows she is in early labor, she should not wear herself out. A tired uterus will not contract as efficiently. Assessment of Labor * The woman's progress is monitored and assessed regularly. * The woman's general condition is observed for signs of fatigue: hydration, energy, nourishment, temperature, pulse. * The position of the baby and the presenting part must be accurately diagnosed. Engagement and station should be noted. * If there is failure of descent, the cause needs to be determined. Is it the cervix, the pelvis, the fetus, the size of the head, weak uterine contractions, etc.? * The uterine contractions are assessed for strength, efficiency, frequency, length, interval, and changes. * Pelvic adequacy and signs of CPD are assessed. Management of Prolonged Labor * Encouragement is provided for the laboring woman. She will need extra support to get through a long labor. * Hydration is maintained. * The woman may eat and drink as desired during early labor. * The bladder is emptied every hour. The urine is checked for ketones every 4 hours to make sure she is not showing signs of exhaustion. * Vaginal exams are performed conservatively under sterile conditions. * The condition of the baby is monitored by checking FHT's and watching for meconium. The baby is closely monitored for signs of stress. Natural Remedies

Many problems can be resolved by creating an atmosphere for the mother in which she feels comfortable and safe. Studies have shown that animals who are scared or otherwise feel unsafe have dysfunctional labors. * A quiet, nonstressful environment will help the woman to move into a natural labor. * Bright lights can cause stress. Dim lights or candles are very soothing. * Positive, comforting words will help her to relax. * A warm bath or shower can help her to relax. Putting women in water works very well. * Going for a walk may help. This will often help the baby's head to be better applied to the cervix and increase the strength and efficiency of contractions. * Try different positions to see which position works best for helping labor to progress. * Nipple stimulation releases natural oxytocin. This works best if both nipples are stimulated at the same time. The nipples should be massaged and pulled on in imitation of how a baby nurses. The nipples are massaged until a contraction starts and then massage is stopped. When the contraction is over massage begins again. * Castor Oil can be used if the woman is having a hard time moving into active labor. The woman should eat a high carbohydrate meal. Two hours later she should drink 2 - 3 oz. of castor oil mixed with 6 oz. of orange juice and 1/2 tsp. of baking soda. This concoction has a very high rate of success if the cervix is at least 2 cm dilated and 50% effaced. * Herbs: Oil of Primrose - rubbed directly on the cervix encourages opening and softening of the cervix. Emotional Aspects It is not uncommon to find an emotional reason that is stalling a woman's labor. If these emotional aspects can be addressed it will often resolve the dysfunctional labor.

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