Module 2

Prolonged Labour

• Majority of childbearing clients anticipate normal labour, vaginal birth.
• Some experience abnormally prolonged labour in first stage (latent/active) or second stage, leading to increased interventions, cesarean births.
• Prolonged labour is challenging for clients & partners.
• Midwives support clients through abnormal labour, recognize abnormalities, apply management techniques, maximize vaginal birth, minimize interventions.

Prolonged Latent First Stage of Labour

• Latent phase: Contractions increase in frequency, duration, intensity; cervical changes (effacement, dilation 0-4 cm).
• Friedman definition: >20 hours (nulliparous), >14 hours (multiparous) = prolonged latent phase. This represents longest normal times & 95th percentile for spontaneous labour.
• Factors influencing prolonged latent phase: unfavorable cervix, transverse/occiput posterior positions.
• Clients with prolonged latent phase achieving eventual normal pattern of dilation/descent aren't more likely to develop arrest disorders than clients with normal latent phase. Perinatal mortality is not increased.
• Lengthy latent phase can be worrisome/tiring for clients, partners, & family. Exhaustion, dehydration can impede active labour progress.
• Client may feel discouraged, anxious: fear inability to endure remaining labour; friends/family worry if labour is normal.
• Prenatal education critical: variation in normal latent phase length; coping strategies; hydration; rest.
• Midwife assessment for reassurance, education on latent phase, active labour signs/symptoms.
• Coping strategies: normal activities (walking, showering), distractions, rest.
• Dimenhydrinate (antihistamine) may promote rest/sleep if client unable to rest.
• Therapeutic rest (narcotic, e.g., morphine): 85% of clients wake in active labour, 10% were not in labour, 5% persistent dysfunctional pattern.
• 30-minute monitoring period after narcotic administation is common. Decision to remain in hospital or discharge for rest considers fetal well-being, narcotic effects, distance from hospital, available driver.
• Majority of clients with prolonged latent phase enter active labour spontaneously if managed expectantly.
• Preventing labour augmentation (e.g., artificial rupture of membranes, oxytocin) is crucial; it increases complications (e.g., cesarean). Dystocia diagnosis requires established active labour.

Prolonged Active First Stage of Labour

• Active first stage: Regular, painful contractions; progressive cervical changes.
• Traditionally defined by cervix fully effaced, four cm dilated; recent evidence suggests active labour may not commence until greater dilation.
• Accurate diagnosis of active labour phase critical for assessment/management.
• Spontaneous labour studies (no oxytocin/epidural): Mean active labour duration: 7.7 hours (nullipara), 5.6 hours (multipara).
• Progress below 5th percentile when dilation < 1 cm/ hour.
• Dystocia: Inadequate labour progress: dilation < 0.5 cm/hour for four hours active first stage, descent < 1 cm/hour second stage.
• Dystocia associated with maternal morbidity (stress, dehydration, infection, pelvic floor injury, uterine rupture, postpartum hemorrhage) & fetal complications (meconium stained fluid, abnormal fetal heart patterns, hypoxia).
• Induction of labour increases risks of dystocia, especially in nulliparous clients with unfavorable cervix.
• Normal labour/vaginal birth relies on fetal/pelvic factors, uterine contractions, & pushing. Aetiology of dystocia involves four Ps: Powers, Passenger, Passage, Psyche.

Powers

• Contractions (hypotonic, ineffective, uncoordinated, infrequent).
• Palpating uterus to assess contraction strength; caput/molding assessment (no caput/molding shows poor contraction quality).

Passenger

• Fetal size, position, attitude.
• Adequate contractions can correct malposition; inadequate can lead to persistence.
• Contraction power can help overcome issues with normal-sized infant with poorly flexed/asynclytic head.
• Relative disproportion may occur if malposition/deflexed/asynclytic fetal head appears to not fit pelvis. True Cephalopelvic Disproportion (CPD) is when well-flexed head cannot pass through pelvis despite adequate uterine contractions.

Passage

• Pelvic structure, space available.
• Prominent ischial spines, sacral promontory, narrow pubic arch can impede passage.
• Full bladder competes for space with fetal head, preventing descent; regular bladder emptying is crucial.

Psyche

• Labouring client's emotional status (fear, anxiety).
• Maternal fear/anxiety produces stress hormones; this weakens uterine contractions.

This quiz explores prolonged labour, focusing on the latent first stage and its implications for midwifery care. Participants will learn about the definitions, influencing factors, and management techniques for clients experiencing abnormal labour. Enhance your understanding of supporting clients through these challenging situations.