Prolonged labor

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Prolonged labor
Other namesFailure to progress
Stages of Childbirth.png
Normal stages of childbirth

Prolonged labor is the inability of a woman to proceed with childbirth upon going into labor. [1] Prolonged labor typically lasts over 20 hours for first time mothers, and over 14 hours for women that have already had children. [1] Failure to progress can take place during two different phases; the latent phase and active phase of labor. [1] The latent phase of labor can be emotionally tiring and cause fatigue, but it typically does not result in further problems. [1] The active phase of labor, on the other hand, if prolonged, can result in long term complications. [1]

Contents

It is important that the vital signs of the woman and fetus are being monitored so preventive measures can be taken if prolonged labor begins. Women experiencing prolonged labor should be under supervision of a surgically equipped doctor. Prolonged labor is determined based on the information that is being collected regarding the strength and time between contractions. Medical teams track this data using intrauterine pressure catheter placement (IUPC) and continuous electronic fetal monitoring (EFM). [2] IUPC is a straw that is inserted into the womb with a monitor that reads when contractions are coming and how strong they are. [2] EFMs are used to track the fetal heart rate. [2] If either devices indicate that vital signs are off and prolonged labor is beginning, it is important that the medical team begin discussing treatment and alternative options for delivery.

Prolonged labor can result from a variety of different issues, such as fetal malpresentation, issues with uterine contractions, cervical dystocia or stenosis, and cephalopelvic disproportion. Both fetal malpresentation and cervical dystocia may result in obstructed labor. [3] The cause of prolonged labor will determine the medical intervention that needs to take place. Medical professionals can either engage in preventive measures or turn to surgical methods of removing the fetus. If not handled properly or immediately treated, both the woman and the fetus can suffer a variety of long term complications, the most serious of which is death. [4] There is no "quick fix" to prolonged labor, but there are preventive measures that can be taken, such as oxytocin infusions. [4] In order to properly and safely deliver the baby, doctors will often intervene in child birth and conduct assisted vaginal delivery through the use of forceps or a vacuum extractor, or perform a Caesarean section. [5]

Signs and symptoms

Symptoms include: [6]

Complications

Prolonged latent labor

The term describes labor that occurs very slowly. [2] This does not necessarily mean that the woman or fetus's health is being compromised, but it is painful and is an important indication for doctors to pay attention to warning signs of prolonged labor. [2]

Prolonged active labor

The phase of labor that extends into multiple hours (at least 14). The cervix usually dilates to over 4 cm before active labor occurs. [7] When it first begins, it is encouraged that women stand up, walk around, and eat or drink. [8] If failure to progress extends beyond this point, preventive measures need to be taken.

Causes

Fetal malpresentations [9]

Fetal malpresentations are irregular positions of the crown of the fetal head in relation to the mother's pelvis (the fetus is in an abnormal position). [9] Some important ways to manage fetal malpresentation are making rapid evaluations of the condition of the women pertaining to vital signs as well as the heart rate of the fetus. [9] If fetal heart rate is abnormal, and if membranes have ruptured and amniotic fluid is atypical, it is important for medical professionals to determine the presenting part of the fetus and the position of the fetal head. [9] Possible delivery methods, if this is the case, are compound presentation, vaginal breech delivery, or caesarean section for breech presentation depending upon the severity of the malposition. [9]

Uterine contractions

This refers to uterine conditions that result in the uterus not having enough coordination or strength to dilate the cervix and push the baby through the birth canal. Issues with uterine contractions are the main cause of prolonged labor during the latent phase. Contractions may not occur as of a result of uterine tumors. In addition, if the uterus is stretched, usually due to previous pregnancies or multiple gestation, contractions may be difficult. Irregular or weak contractions can be fixed through stimulation of the uterus or oxytocin infusions. Lack of contractions may be caused by an overwhelming amount of painkillers or anesthesia, by which the medications should be discontinued. In this case, it is appropriate for assisted vaginal delivery to be conducted.

Cervical stenosis

Cervical dystocia, or stenosis, occurs when the cervix fails to dilate after a practical amount of time during positive uterine pains. The main problems in cervical dystocia is the lack of uterine inertia and cervical abnormalities, which prevent the cervix from fully dilating. [10] It is very typical of patients that have hypopituitarism. [11] There are many preexisting complications that may result in stenosis. Common conditions that lead to stenosis are tumors, a full bladder, large size of the infant, multiple pregnancies, delay in rupture of membranes, or problems with the cervix. [11] High stress may interfere with the progression of pregnancy in cases such as these, leading to prolonged labor. [11]

Cephalopelvic disproportion

Cephalopelvic disproportion is the issue that arises when the fetus' body or head is too large to pass through the woman’s pelvis. [12] Common conditions that lead to CPD are diabetes, multiple pregnancies, small or abnormally shaped pelvis, atypical fetal positions, hereditary factors, and first time pregnancies. [12] Medical professionals can usually estimate if fetal size is too large based on ultrasounds, but they are not always entirely accurate. [12] Doctors typically determine CPD when labor begins and the use of oxytocin is not effective. The safest way for delivery to take place when CPD is a factor is through Caesarean sections. [12]

Prevention

If the woman is being closely monitored and begins to show signs of prolonged labor, medical professionals can take preventive measures to better the chances of delivery within 24 hours. [4] A precise initial diagnosis of prolonged labor based on signs and symptoms is extremely important in applying proper precautionary treatment. [4] Oxytocin infusions upon an initial amniotomy is typically used to move normal labor back on track. [4] The application of oxytocin is only effective if administered on the basis of fetal distress. [4] This treatment method only pertains to specific states of the fetus. If the baby is experiencing malpresentation, for example, the only safe and reliable method to proceed with childbirth is medical interference. [4]

Management

In terms of medical care, preventive treatment or assisted delivery are typically the first options doctors consider. There is usually no quick fix to prolonged labor, especially if preventive measures do not revert the mother back to normal labor. Often, medical professionals resort to intervention methods. If the state of the fetus and mother are not especially serious or threatening to their health, doctors will perform assisted vaginal deliveries.

Assisted vaginal delivery

There are two different methods of assisted vaginal delivery that medical professionals typically utilize to aid in delivery in order to avoid surgical methods of fetal extraction. These procedures are only applied if a vaginal delivery has proven to still be safe to the woman and the baby, based on their vital signs. Assisted vaginal delivery is usually only used in the latent phase. [5] Delivery during the active phase is usually associated with more complications for the woman. [5] One approach to assisted vaginal delivery is the use of forceps. [5] The forceps doctors use resemble two large salad spoons and are inserted into the cervix, around the baby's head and help to guide it out of the birth canal. [5] The other option is the use of vacuum extraction. Vacuums used have a cup on the end and are inserted into the cervix. [5] The cup attaches to the fetus's head by suction and aids in guiding delivery. The choice between forceps and vacuum extraction is usually made by the doctor based on preference. It is important that these methods are used properly, or else they can cause severe birth injuries to the baby that may be permanent. [5]

Caesarean sections

Caesarean sections, also referred to as C-sections, are usually quick solutions to the issue of failure to progress. Often, C-sections are the best options to avoid harming the fetus or the woman, especially if labor proves to be life-threatening. One third of C-sections occur as a result of prolonged labor. [1] C-sections are usually a necessary measure in prolonged labor to avoid serious birth complications. If the mother reaches the active phase of prolonged labor, a C-section is the safest solution. Caesarean sections need to be performed immediately if there are signs of fetal distress, uterine rupture, or cord prolapse. It is important that medical professionals are equipped and prepared in the case of an imperative C-section. There is a window of time by which Caesarean sections need to be executed if any warning signs present themselves. If there is a delay in the C-section, permanent damage can result to the baby, such as cerebral palsy or hypoxic-ischemic encephalopathy (HIE). Due to all the risk factors that are present in the event of prolonged labor, it is extremely important that medical teams are well-suited and prepared to conduct a C-section if needed.

Related Research Articles

<span class="mw-page-title-main">Cervix</span> Lower part of the uterus in the human female reproductive system

The cervix or cervix uteri is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long and roughly cylindrical in shape, which changes during pregnancy. The narrow, central cervical canal runs along its entire length, connecting the uterine cavity and the lumen of the vagina. The opening into the uterus is called the internal os, and the opening into the vagina is called the external os. The lower part of the cervix, known as the vaginal portion of the cervix, bulges into the top of the vagina. The cervix has been documented anatomically since at least the time of Hippocrates, over 2,000 years ago.

<span class="mw-page-title-main">Childbirth</span> Expulsion of a fetus from the pregnant mothers uterus

Childbirth, also known as labour, parturition and delivery, is the completion of pregnancy where one or more babies exits the internal environment of the mother via vaginal delivery or caesarean section. In 2019, there were about 140.11 million human births globally. In the developed countries, most deliveries occur in hospitals, while in the developing countries most are home births.

<span class="mw-page-title-main">Breech birth</span> Birth of a baby bottom first

A breech birth is when a baby is born bottom first instead of head first, as is normal. Around 3–5% of pregnant women at term have a breech baby. Due to their higher than average rate of possible complications for the baby, breech births are generally considered higher risk. Breech births also occur in many other mammals such as dogs and horses, see veterinary obstetrics.

<span class="mw-page-title-main">Misoprostol</span> Medication to induce abortion and treat ulcers

Misoprostol is a synthetic prostaglandin medication used to prevent and treat stomach and duodenal ulcers, induce labor, cause an abortion, and treat postpartum bleeding due to poor contraction of the uterus. It is taken by mouth when used to prevent gastric ulcers in people taking nonsteroidal anti-inflammatory drugs (NSAID). For abortions it is used by itself or in conjunction with mifepristone or methotrexate. By itself, effectiveness for abortion is between 66% and 90%. For labor induction or abortion, it is taken by mouth, dissolved in the mouth, or placed in the vagina. For postpartum bleeding it may also be used rectally.

<span class="mw-page-title-main">Placenta praevia</span> Medical condition

Placenta praevia is when the placenta attaches inside the uterus but in a position near or over the cervical opening. Symptoms include vaginal bleeding in the second half of pregnancy. The bleeding is bright red and tends not to be associated with pain. Complications may include placenta accreta, dangerously low blood pressure, or bleeding after delivery. Complications for the baby may include fetal growth restriction.

Labor induction is the process or treatment that stimulates childbirth and delivery. Inducing (starting) labor can be accomplished with pharmaceutical or non-pharmaceutical methods. In Western countries, it is estimated that one-quarter of pregnant women have their labor medically induced with drug treatment. Inductions are most often performed either with prostaglandin drug treatment alone, or with a combination of prostaglandin and intravenous oxytocin treatment.

Cervical dilation is the opening of the cervix, the entrance to the uterus, during childbirth, miscarriage, induced abortion, or gynecological surgery. Cervical dilation may occur naturally, or may be induced surgically or medically.

Bloody show or show is the passage of a small amount of blood or blood-tinged mucus through the vagina near the end of pregnancy. It is caused by thinning and dilation of the cervix, leading to detachment of the cervical mucus plug that seals the cervix during pregnancy and tearing of small cervical blood vessels, and is one of the signs that labor may be imminent. The bloody show may be expelled from the vagina in pieces or altogether and often appears as a jelly-like piece of mucus stained with blood. Although the bloody show may be alarming at first, it is not a concern of patient health after 37 weeks gestation.

<span class="mw-page-title-main">Obstructed labour</span> Medical condition

Obstructed labour, also known as labour dystocia, is the baby not exiting the pelvis because it is physically blocked during childbirth although the uterus contracts normally. Complications for the baby include not getting enough oxygen which may result in death. It increases the risk of the mother getting an infection, having uterine rupture, or having post-partum bleeding. Long-term complications for the mother include obstetrical fistula. Obstructed labour is said to result in prolonged labour, when the active phase of labour is longer than 12 hours.

<span class="mw-page-title-main">Prelabor rupture of membranes</span> Medical condition

Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, is breakage of the amniotic sac before the onset of labor. Women usually experience a painless gush or a steady leakage of fluid from the vagina. Complications in the baby may include premature birth, cord compression, and infection. Complications in the mother may include placental abruption and postpartum endometritis.

<span class="mw-page-title-main">Cervical effacement</span>

Cervical effacement or cervical ripening refers to the thinning and shortening of the cervix. This process occurs during labor to prepare the cervix for dilation to allow the fetus to pass through the vagina. While this a normal, physiological process that occurs at the later end of pregnancy, it can also be induced through medications and procedures.

Prostaglandin E<sub>2</sub> Chemical compound

Prostaglandin E2 (PGE2), also known as dinoprostone, is a naturally occurring prostaglandin with oxytocic properties that is used as a medication. Dinoprostone is used in labor induction, bleeding after delivery, termination of pregnancy, and in newborn babies to keep the ductus arteriosus open. In babies it is used in those with congenital heart defects until surgery can be carried out. It is also used to manage gestational trophoblastic disease. It may be used within the vagina or by injection into a vein.

Postterm pregnancy is when a woman has not yet delivered her baby after 42 weeks of gestation, two weeks beyond the typical 40-week duration of pregnancy. Postmature births carry risks for both the mother and the baby, including fetal malnutrition, meconium aspiration syndrome, and stillbirths. After the 42nd week of gestation, the placenta, which supplies the baby with nutrients and oxygen from the mother, starts aging and will eventually fail. Postterm pregnancy is a reason to induce labor.

<span class="mw-page-title-main">Uterine atony</span> Loss of tone in the uterine musculature

Uterine atony is the failure of the uterus to contract adequately following delivery. Contraction of the uterine muscles during labor compresses the blood vessels and slows flow, which helps prevent hemorrhage and facilitates coagulation. Therefore, a lack of uterine muscle contraction can lead to an acute hemorrhage, as the vasculature is not being sufficiently compressed. Uterine atony is the most common cause of postpartum hemorrhage, which is an emergency and potential cause of fatality. Across the globe, postpartum hemorrhage is among the top five causes of maternal death. Recognition of the warning signs of uterine atony in the setting of extensive postpartum bleeding should initiate interventions aimed at regaining stable uterine contraction.

<span class="mw-page-title-main">Vaginal delivery</span> Delivery through the vagina

A vaginal delivery is the birth of offspring in mammals through the vagina. It is the most common method of childbirth worldwide. It is considered the preferred method of delivery, with lower morbidity and mortality than caesarean sections (C-sections).

An asynclitic birth or asynclitism are terms used in obstetrics to refer to childbirth in which there is malposition of the head of the fetus in the uterus, relative to the birth canal. Asynclitic presentation is different from a shoulder presentation, in which the shoulder is presenting first. Many babies enter the pelvis in an asynclitic presentation, and most asynclitism corrects spontaneously as part of the normal birthing process.

<span class="mw-page-title-main">Shoulder presentation</span> Medical condition

A shoulder presentation is a malpresentation at childbirth where the baby is in a transverse lie, thus the leading part is an arm, a shoulder, or the trunk. While a baby can be delivered vaginally when either the head or the feet/buttocks are the leading part, it usually cannot be expected to be delivered successfully with a shoulder presentation unless a cesarean section (C/S) is performed.

<span class="mw-page-title-main">Cephalic presentation</span> Medical condition

A cephalic presentation or head presentation or head-first presentation is a situation at childbirth where the fetus is in a longitudinal lie and the head enters the pelvis first; the most common form of cephalic presentation is the vertex presentation, where the occiput is the leading part. All other presentations are abnormal (malpresentations) and are either more difficult to deliver or not deliverable by natural means.

A uterotonic, also known as an oxytocic or ecbolic, is a type of medication used to induce contraction or greater tonicity of the uterus. Uterotonics are used both to induce labor and to reduce postpartum hemorrhage.

<span class="mw-page-title-main">Emergency childbirth</span>

Emergency childbirth is the precipitous birth of an infant in an unexpected setting. In planned childbirth, mothers choose the location and obstetric team ahead of time. Options range from delivering at home, at a hospital, a medical facility or a birthing center. Sometimes, birth can occur on the way to these facilities, without a healthcare team. The rates of unplanned childbirth are low. If the birth is imminent, emergency measures may be needed. Emergency services can be contacted for help in some countries.

References

  1. 1 2 3 4 5 6 "Prolonged Labor: Failure to Progress - Causes and Solutions". American Pregnancy Association. 2014-08-15. Retrieved 2018-12-07.
  2. 1 2 3 4 5 "Prolonged Labor: Causes and Treatment". WebMD. Retrieved 2018-12-07.
  3. ↑ Education material for teachers of midwifery : midwifery education modules. Geneva [Switzerland]: World Health Organization. 2008. pp. 17–36. ISBN   9789241546669.
  4. 1 2 3 4 5 6 7 Gallagher, John T.; Jackson, Reginald J. A.; O'Driscoll, Kieran (1969-05-24). "Prevention of Prolonged Labour". Br Med J. 2 (5655): 477–480. doi:10.1136/bmj.2.5655.477. ISSN   1468-5833. PMC   1983378 . PMID   5771578.
  5. 1 2 3 4 5 6 7 "Procedures That May Take Place During Labor and Delivery". pennmedicine.adam.com. Retrieved 2018-12-08.
  6. ↑ "Prolonged Labor can occur due to cpd, malpresentations, uterine inertia etc". Gynaeonline. Retrieved 2018-10-25.
  7. ↑ "Protracted Labor - Gynecology and Obstetrics". Merck Manuals Professional Edition. Retrieved 2018-12-08.
  8. ↑ Nystedt, Astrid; Hildingsson, Ingegerd (2014-07-16). "Diverse definitions of prolonged labour and its consequences with sometimes subsequent inappropriate treatment". BMC Pregnancy and Childbirth. 14 (1): 233. doi: 10.1186/1471-2393-14-233 . ISSN   1471-2393. PMC   4105110 . PMID   25031035.
  9. 1 2 3 4 5 "MCPC - Malpositions and malpresentations - Health Education To Villages". hetv.org. Retrieved 2018-12-06.
  10. ↑ Arthur, Hugh R. (1949-12-01). "Cervical Dystocia". BJOG: An International Journal of Obstetrics & Gynaecology. 56 (6): 983–993. doi:10.1111/j.1471-0528.1949.tb07164.x. ISSN   1471-0528. PMID   15410101. S2CID   40011612.
  11. 1 2 3 Arnot, Philip H. (January 1952). "PROLONGED LABOR". California Medicine. 76 (1): 20–22. ISSN   0008-1264. PMC   1521210 . PMID   14886755.
  12. 1 2 3 4 "Cephalopelvic Disproportion (CPD): Causes and Diagnosis". American Pregnancy Association. 2012-04-26. Retrieved 2018-12-06.
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