Prevention, Diagnosis and Treatment of protracted Labor Dr. Mohammed Abdalla

Guideline Objective To prevent unnecessary protracted labor To increase the use of procedures that assist in progress to vaginal birth

Unsatisfactory progress of labour Cervix not dilated No palpable contractions/infrequent contractions False labour

Unsatisfactory Progress of Labour Cervix not dilated beyond 4 cm after 8 hours of regular contractions Prolonged latent phase

Unsatisfactory progress of labour Less than three contractions in 10 minutes, each lasting less than 40 seconds Inadequate uterine contractions

Unsatisfactory Progress of Labour Cervical dilatation to the right of the alert line on the partograph Prolonged active phase

Unsatisfactory progress of labour Cephalopelvic disproportion Secondary arrest of cervical dilatation and descent of presenting part in presence of good contractions Cephalopelvic disproportion

Unsatisfactory progress of labour Secondary arrest of cervical dilatation and descent of presenting part with large caput, third degree moulding, cervix poorly applied to presenting part, oedematous cervix, ballooning of lower uterine segment, formation of retraction band, maternal and fetal distress Obstruction

1. Confirm Active Labor Before Admitting to Facility Spontaneous contractions at least 2 per 15 minutes, and two or more of the following : Complete effacement of cervix Cervical dilation greater than or equal to 3 cm Spontaneous rupturing of membranes (SROM)

2. Perform Amniotomy Early in Labor Spontaneous rupture of membranes Presentation unknown, floating or unstable Cervix dilated less than 3 cm Patient refuses Perform amniotomy early in labor unless one or more of the following occurs:

3-conduct Frequent Cervical Checks Cervical checks should indicate at least 1 cm dilation per hour Failure to progress is defined as cervical changes of less than 1 cm per hour for 2 consecutive hours.

Partograph and Criteria for Active Labor Label with patient identifying information Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given Plot cervical dilation Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour Action line: if patient does not progress as above, action is required The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor. At the alert line, the onset of the active phase of labor (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labor.

4-Augment with Oxytocin to achieve adequate labor for 2 to 4 hours.

In multigravida and in previous C.S. 2.5 U Oxytocin in 500 ml. G. 5% In multigravida and in previous C.S. 15 drops / min increase infusion rate by 15 drops every 30 minutes When contractions lasting more than 40 seconds and occurring three times in 10 minutes). maintain infusion If good contractions are not established at 60 drops per minute . 5 units in 500 mL dextrose 30drops / min increase infusion rate by 15 drops every 30 minutes If good contractions are not established at 60 drops per minute do c.s.

increase infusion rate by 15 drops increase infusion rate by 15 drops 5 units Oxytocin in 500 mL dextrose In primigravida 30 drops / min increase infusion rate by 15 drops every 30 minutes When contractions lasting more than 40 seconds and occurring three times in 10 minutes). maintain infusion If good contractions are not established 60 drops per minute . 10 units in 500 mL dextrose 30 drops / min increase infusion rate by 15 drops every 30 minutes If good contractions are not established at 60 drops per minute do c.s.

Uterine Hyperstimulation Is defined as contractions lasting longer than 90 seconds, OR more than five contractions in 10 minutes can be managed by changing the maternal position and administering oxygen, shutting off the pitocin until recovery has occurred and possibly the administration of terbutaline 0.25 mg SC.

Category Definition Normal A CTG where all four features fall into the reassuring category. Suspicious A CTG whose features fall into one of the non-reassuring categories and the remainder of the features are reassuring. Pathological A CTG whose features fall into two or more non-reassuring categories or one or more abnormal categories.

5-If patient is in Stage II labour and is not making progress Positioning. Fluid balance. Oxytocin augmentation. Obstetrical/surgical consult.

6- Consider operative vaginal delivery or cesarean delivery THANK YOU