7.1 Prolonged labour


Excessively prolonged dilation or delivery. The term “prolonged labour” applies only at or after 4 cm dilation and 3 contractions per 10 minutes. Before that point, it is usually a question of “false labour” (i.e. prolonged latent phase).

Prolonged labour can be due to foeto-pelvic disproportion (mechanical dystocia) and/or inadequate contractions (dynamic dystocia).

The main risks of prolonged labour are obstruction (Section 7.2) and foetal distress.

7.1.1 Diagnosis

– Protracted cervical dilation (dilation progresses less than 1 cm/hour during the active phase);
or
– The foetus has failed to engage after more than 1 hour of complete dilation in a multipara and 2 hours of complete dilation in a primipara;
or
– The active pushing phase until birth of the infant is longer than 30 minutes in multipara and 1 hour in primipara.

7.1.2 Management

See algorithms below.
For general patient care during labour, see Chapter 5, Section 5.1.4.

Notes:

– Oxytocin is contra-indicated in case of frank foeto-pelvic disproportion (risk of uterine rupture).

– In case of foetal distress (prolonged deceleration of the foetal heart rate to less than 100 beats per minute after each uterine contraction) and if the foetus is viable:

• At complete dilation, with the presenting part engaged: instrumental delivery (Chapter 5, Section 5.6);

• Prior to complete dilation, or at complete dilation with presenting part not engaged: consider caesarean section earlier than in the algorithms, but the context needs to be taken into account when deciding a caesarean section for exclusive foetal indication (Chapter 6, Section 6.4).

In either case, do not use—or stop, if already using—oxytocin.

– If the foetus is dead, avoid caesarean section whenever possible. Allow more time for dilation and engagement. Consider embryotomy (Chapter 9, Section 9.7).


Management of protracted cervical dilation
Crossing of the partograph action line or more than 4 hours at the same dilation

For other presentations, see Breech presentation (Chapter 6, Section 6.1), Transverse lie and shoulder presentation (Section 7.6), Face presentation (Section 7.9), Brow presentation (Section 7.10).


Management of protracted foetal descent at complete dilation
No engagement after 1 hour (multipara) and 2 hours (primipara) and/or no delivery despite good expulsive efforts after 30 minutes (multipara) and 1 hour (primipara)

For other presentations:
Breech presentation: caesarean section or, in rare cases, manoeuvres (do not attempt any manoeuvre on a non-engaged breech);
Shoulder, chin-posterior face, or brow presentation: caesarean section.