Prolonged Labor

Introduction[edit | edit source]

Prolonged labor also know as Labor dystocia is a labor complication common in nulliparous women that may disrupt the process of vaginal delivery making it a major indication for instrumental deliveries or/ and cesarean section (CS).[1] It may increase the risk for maternal and neonatal infection, fetal distress, neonatal hypoxia, uterine rupture, and postpartum hemorrhage. It may also increase the risk of maternal pelvic floor and genital trauma.[2]

Labor dystocia(LD) can not be described without describing the process of normal labor process. Normal labor is described as uterine contractions that leads to progressive dilation and effacement of the cervix. Labor dystocia (LD) caused by fetal malposition, inadequate contractions, poor maternal efforts, or true cephalopelvic disproportion.[3] Management of LD can significantly affect the outcome of the delivery process.

Definition[edit | edit source]

WHO defined labor dystocia as the "onset of regular, rhythmical painful contractions accompanied by cervical dilation where labor is longer than 24 hours".[4]

Pathophysiology[edit | edit source]

Labor dystocia can be the result of problems with one of the following three P' s:

  1. Passenger: The passenger is referred to the fetus travelling down the birth canal. When the fetal head is large in proportion to the mother's pelvis, or not in proper position. In this situation, spontaneous vaginal delivery will be difficult and there will be need for assisted delivery or a caesarean section.
Types of female pelvis

2. Pelvic or passage size: The shape and deformity of the pelvis has been implicated in labor dystocia. The female pelvis has four shapes. Caldwell and Moloy grouped the female pelvis into four different types gynoid, android, anthropoid, and platypelloid. Each has peculiar characteristics regarding the width of the sub-pubic angle, the height of the pelvis, the transverse diameters of the three pelvic planes (inlet, mid pelvis, outlet), and the shape of the circumference of the upper pelvis.[5] The commonest (50%) and most favorable in Caucasian women is the gynoid. It is described to be ovoid in shape and has a round inlet (Anteroposterior diameter of 11 cm and transverse diameter of 13 cm) for fetal head to engage and descend through its wide subpubic arch. The second and third pelvic shapes increase the incidence of occipito-posterior positions. Engagement of the fetal head is always almost impossible with a platypelloid pelvis.[6]

3. Power (uterine contractility): This refers to the strength of the uterine contractions in the first and second stage of labor. The strength of uterine contractions plays an important role in the progress of labor. Asma and Tahir stated that in 20% of cases, the occiput is posterior at the beginning of labor and with good uterine contractions, in almost 90% of these cases, the vertex will rotate to an occipito-anterior position.[6] During the second stage of labor, more strength is required by the mother to push. Ineffective maternal pushing efforts in the second stage of labor might lead to labor dystocia

Diagnosis[edit | edit source]

It is essential to diagnose labor dystocia early so that prompt interventions can be offered to improve progress of labor and therefore reduce maternal and fetal morbidities that may be caused by LD. The partograph is used in establishing a diagnosis of labor dystocia. Recommended by the World Health Organization,[7] a partograph (or partogram) is a tool used for monitoring labor wellbeing and progress[8]can as well be used to prevent[9] labor dystocia.

Labor progress is said to be abnormal when the rate of dilatation falls to the right of the projected normal labor curve plotted on the partograph. Delay in the first stage of labor is suspected if there is cervical dilatation of less than 2 cm in 4 h. Delay in the second stage of labor is diagnosed once the stage is more than 2 hours in Nulliparous or less than 1hour per descent in multiparous women.[3]

Complications of labor dystocia[edit | edit source]

The complications can be maternal or neonatal.The maternal complications[10] include:

  • Perineal tear

The fetal complications include:

  • Birth asphyxia which can sometimes be referred to as Hypoxic-Ischaemic Encephalopathy; it is a condition that affects the normal exchange of respiratory gases which leads to a decrease in blood oxygen level and is accompanied by acid build up (metabolic acidosis). This leads to brain damage.[11]

This can cause serious affectation of a part of the brain giving rise to:

  • physical disabilities
  • Cerebral palsy
cerebral palsy

Managements of labor dystocia[edit | edit source]

The goal of management is to optimize delivery outcome for both the mother and the fetus. Management is describe in 2 phases; Active management is where one anticipates and starts action before the problems arise rather than passive management where one acts only when the problems arise.[12]

The active phase starts with education in the antenatal period and continues into labor. Its components are;

  • Education of the pregnant mother,
  • Strict criteria for diagnosis of labor,
  • Early amniotomy,
  • Monitoring progress of labor.

Physiotherapy can help in prevention and management of labor dystocia. Upright positions during the first stage of labor has been associated with shortened labor period,[13] enhance uterine contractions, fetal condition, promotion of maternal comfort[14],[15]and expands pelvic outlet[15]. Other physiotherapy modalities for labor management can be employed; see labor

References[edit | edit source]

  1. (Lowe NK: A Review of factors associated with dystocia and Cesarean section in nulliparous women. J Midwifery womens health. 2007,52(3):216-228, American College of Obstetrics and Gynecology. ACOG practice bulletin number 49, December 2003: dystocia and augmentation of labor. Obstet Gynecol. 2003;102:1445–54.
  2. Sheiner E, Levy A, Feinstein U, et al. Risk factors and outcome of failure to progress during the first stage of labor: a population-based study. Acta Obstet Gynecol Scand. 2002 Mar;81(3):222–6. PMID: 11966478.
  3. 3.0 3.1 Shields S, Ratcliffe S, Fontaine P, Leeman L. Dystocia in nulliparous women. American family physician. 2007 Jun 1;75(11):1671-8.
  4. World Health Organization. Education material for teachers of midwifery: midwifery education modules.
  5. Swekson PC. Anatomical Variations in the Female Pelvis: The Caldwell-Moloy Classification. Radiology. 1947 May;48(5):527-8.
  6. 6.0 6.1 Gharaibeh A, Mahmood T. Abnormal labour. Obstetrics, Gynaecology & Reproductive Medicine. 2019 May 1;29(5):129-35.
  7. World Health Organization. Partograph in management of labour. World Health Organization maternal health and safe motherhood programme. Lancet. 1994;343:1399-404.
  8. Bedwell C, Levin K, Pett C, Lavender DT. A realist review of the partograph: when and how does it work for labour monitoring?. BMC pregnancy and childbirth. 2017 Dec;17(1):1-1.
  9. Mathews M. The partograph for prevention of obstructed labour. Clin Obstet Gynaecol. 2009;52(2):256-69.
  10. Hagiwara M, Nakanishi S, Shindo R, Obata S, Miyagi E, Aoki S. An extremely prolonged second stage of labor increases maternal complications but has no adverse effect on neonatal outcomes. J Obstet Gynaecol Res. 2022 Jun;48(6):1364-1369. doi: 10.1111/jog.15212. Epub 2022 Mar 13. PMID: 35285119.
  11. Collins KA, Popek E. Birth Injury: Birth Asphyxia and Birth Trauma. Acad Forensic Pathol. 2018 Dec;8(4):788-864. doi: 10.1177/1925362118821468. Epub 2018 Dec 19. PMID: 31240076; PMCID: PMC6491540.
  12. El-Hamamy E, Arulkumaran S. Poor progress of labour. Current Obstetrics & Gynaecology. 2005 Feb 1;15(1):1-8.
  13. Lawrence A, Lewis L, Hofmeyr GJ, Styles C. Maternal positions and mobility during first stage labour. Cochrane database of systematic reviews. 2013(8).
  14. Simkin PP, O'hara M. Nonpharmacologic relief of pain during labor: systematic reviews of five methods. American journal of obstetrics and gynecology. 2002 May 1;186(5):S131-59.
  15. 15.0 15.1 Kibuka M, Thornton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews. 2017(2).