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| Home > Complication & Medications > Prolonged Labor
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| | Prolonged Labor
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A labor with duration of more than twenty-four hours is considered a prolonged labor. There are two different phases of labor, a latent phase (pre-labor phase) and an active phase. A lengthy latent phase doesn`t necessarily mean an obstetrical problem. It implies that the rate of cervical dilation is slow. It just induces discouragement, exhaustion and may drain you emotionally. Other than that it doesn`t result in any medical problem. On the other hand, an active labor which slows or stops may later turn into a complication.
Prolonged Labor (First Phase)
A long latent phase (labor that is slow in starting) does not preclude a prolonged labor. Once the active phase starts, the labor usually progresses at a normal rate In most cases. It may imply that your early con-tractions are ripening or effacing the cervix before labor, so that it can proceed with the job of opening the cervix.
Recommendations
Do not be disheartened or depressed. Try different activities like eating, drinking, taking a bath or a shower, or a gentle massage alternated with a walk, food or drink will boost your morale. Swap between rest and activity. Try various methods to stimulate labor Keeping your mind off the contractions will help. Activities like watching a movie, a chat with friends or even a shopping trip will enliven you.
Medical Care
When a latent phase exhausts you or lasts for duration of over twenty-four hours, medical interventions may be necessary for you. This can be done in two ways: first by trying to stop contractions with medication (such as mor-phine) and giving you rest, secondly by inducing effective contractions with procedures such as stripping the membranes, administer-ing an enema, or giving drugs that ripen the cervix or induce labor (such as Pitocin).
Prolonged Labor (Active Phase)
The stopping or slowing of labor at the beginning of active phase is considered a more serious problem than a prolonged latent phase. The different factors that lead to a prolonged active phase can vary from inefficient uterine contractions, an unfavorable presentation or position of the baby and a small pelvis. The other causes could be a combination of the following factors like Immobility, restriction to bed, a full bladder, drugs that slow or stop labor, fear, anxiety, and stress.
Recommendations
The problem needs to be identified for finding a solution. For instance, the baby`s descent may be arrested by the mother`s full bladder. So emptying the bladder every hour is advisable. The drugs taken to slow your labor will wear off with time. You may excrete the drug rapidly by walking and drinking liquids. Changing position is another option especially gravity induced one. If you have been lying still in one position, try walking or standing (positions that make use of gravity), or try shifting positions in bed from side to side. Sometimes sitting followed with resting on your hands and knees help. These positions can be used even if you are attached to intraven-ous fluids and an electronic fetal monitor. Nipple stimulation, walking, and standing also enhance the effec-tiveness of contractions.
In case you are drained out, tired and afraid, you will need hope and a lot of encouragement from your partner as well as the hospital staff. They should help with relaxation, and other comfort measures such as a massage or shower. These resources can sustain you through your troubled times.
The Occiput Posterior
 Slow progress and descent can sometimes be attributed to the position of the baby in the pelvis. The most common position is occiput post-erior (OP) where the back of the baby`s head is toward the mother`s back. One out of four women starts labor in this position. This position is linked with longer labors, since the baby needs to rotate further to get to the anterior position for birth. Dilatation and descent is hampered considerably when the baby is OP. By transition, however, most babies in the OP position turn to an occiput anterior position, though some turn even later. Other "persistent" occiput post-erior babies are born in that position with their faces toward their mother`s front (sometimes called a "sunny side up" delivery).
You will suffer considerable back pain during and sometimes between contractions if your baby is OP. The pain is caused by the pressing of the hard round part of your baby`s head (the occiput) on your sacrum (low back), straining the sacroiliac joints and causing pain in the entire low back area.
There are specific, effective ways to deal with the occiput post-erior position and the resulting backache.
Change your position every twenty to thirty minutes to facilitate the baby`s turning to take advantage of gravity and movement.
Stand or walk to try to align the baby`s body with the entrance to the pelvis and enhance pelvic mobility.
Get into the hands and knees position so gravity can as-sist rotation. (In the hands and knees position. gravity en-courages the OP baby`s trunk to drop toward your abdomen.)
Do the pelvic rock while on your hands and knees to pro-vide movement which may free the baby`s head from the pelvis and allow it to turn to an anterior position.
Use these measures to help relieve the back pain.
Use positions that prevent the baby`s head from pressing on your back
Ask your partner or attendant to use counter-pres-sure on the painful area. To apply counter-pressure yourself, press your fists into your low back or lean back on your fists or another hard object such as a tennis ball.
Ask your partner for a back massage.
Use cold or hot packs on your low back during or between contractions.
Stand or sit in the shower and let the water spray on the painful area.
Continue using relaxation and breathing techniques.
If necessary, use pain medications.
Medical Care
The progress of your labor and the well-being of your baby is of utmost concern to your doctor if you go through a prolonged active phase .Vaginal exams would become very frequent to assess the progress in dilatation, descent, or rotation. The fetal heart rate also needs to be monitored more often with the electronic fetal monitor. You need to be put on Intravenous fluids to prevent dehydration. You may need medications for relaxation and pain relief if your labor is overly long. In order to enhance labor, your doctor may rupture the membranes. Pitocin will help you to increase the frequen-cy and intensity of your contractions. Cesarean birth may become necessary If the baby is under stress, as indicated by the fetal heart rate in response to contractions, and labor continues to lag. You may if you want to, take part in the decisions.
Prolonged Labor (Second Stage)
Generally the reasons that cause a prolonged active phase labor are the same as the cessation of labor after the cervix is fully dilated. Most prolonged second stages can be handled as described for prolonged active phase. But there are other specific problems that can arise only in second stage. If the inlet (upper part) of the pelvis is large enough for the baby to enter, but the outlet (lower part) is too narrow to allow rotation or descent, progress can be delayed. This Problem can arise only if the baby descends quite low in the pelvis. A short cord, though rarely found, is another problem which hinders the descent of the baby or causes the fetal heart rate to slow during contractions.
The third problem is rather a rare one occurring in very broad shouldered babies called shoulder dystocia -. This serious complication arises after the head is born and when the shoulders are so broad they are unable to pass through the pelvis. A cesarean section is not recommended for this state since the head is already born. Instead, the doctor or midwife may, with the cooperation of the mother, should skillfully twist and turn the baby to deliver the shoulders. The only thing that has to be kept in mind is that time should not be wasted, since the baby`s oxygen supply from the cord may be reduced.
Recommendations
Gravity enhancing positions will help you tide over the problem with descent during the second stage. Give each position a time of about twenty to thirty minutes, If there is no apparent progress in one position, change again. Find out which position is effective by trial and error. Squatting causes maximum enlargement of the pelvic outlet while using gravity is the best aid to descent. This position may enhance the space for a baby in the occiput posterior position to rotate, or enlarge a relatively small pelvic outlet enough for the baby to pass through. Other positions which are worth trying are standing, semi sitting and hands and knees positions.
When effective bearing down is hindered by the tension in the perineum even with hot compresses and reminders to re-lax, sitting on the toilet may encourage release of the perine-um. To get the baby moving, prolonged pushing with more forceful bearing down needs to be done. Changing positions may also help sometimes. At this stage the advantages of prolonged pushing may outweigh the disadvantages. Your birth attendant directs your pushing at this time.
Medical Care
The pro-longed second stage necessitates close medical observation. The fetal heart rate has to be monitored to see that the contractions and your positions are not putting the fetus on stress. Here you should know that if you are on your back you might cause fetal distress. If the fetus is not stressed, then the obstetrician will wait for natural delivery and encourage you to continue your efforts. On the other hand, if your contractions are not effective enough or you have received medications which slow down your labor, or getting poor response of the fetus, then he may recommend the various available form of surgical delivery such as vacuum extraction, Episiotomy, forceps delivery and cesarean section.
Difficult Presentations
About 95 percent of the time, the baby is in vertex presentation. Face and brow presentations occurring in about less than 0.5percent of the time cause prolonged labors and are managed as such. The shoulder presentation (transverse lie) is a rare occurrence, in about 1 in 500 births. A cesarean delivery is usually necessary in the shoulder presentation because a baby in this position does not turn to a head-down presenta-tion position. Finally, the breech presentation (with buttocks. legs. or feet over the cervix) occurs 3 to 4 percent of the time. (The incidence rises with pre maturity or twins.) This is the most common of the difficult presentations.
There are four types of breech presentations:
Frank: -buttocks down and legs straight up toward the face
Complete-sitting cross-legged
Footling-one or both feet down and
Kneeling -one or both knees down.
The most common position among the breech position is the frank breech. Though breech deliveries are riskier to both baby and mother than the vertex presentation but they usually turn out well.
Risks to the baby
The chances of cord prolapse or the descent of the umbilical cord through the cervix into the vagina increases. A breech presentation is a rare but extremely serious complication occurring in case of ruptured membranes. Cord prolapse occurs when the cord is squeezed between the baby and the birth canal thereby severely depriving oxygen to the baby espe-cially during contractions. This is a life-threatening emergency. In case your membranes rupture and your are aware that your baby is breech (or transverse), you should lie down to prevent gravity from pressing the baby onto the cord, A knee-chest position is also useful in this case. You should shift to the hospital in a supine position.
If the baby`s feet and body are delivered before his head as in the case of vaginal birth of a breech, the baby`s head can compress the cord within the pelvis, reducing the oxygen flow from the placenta to the baby and endangering the baby. If the feet and buttocks which are small enough are born before the dilation of the cervix, the head may be entrapped in the bony pelvis and the fetus may inhale amniotic fluid. Another risk is spinal cord injury, if the head of the fetus is hyper extended (bent back).
The mother experiencing a vaginal breech delivery can suffer lacerations of the birth canal and possible hemorrhage which are considerably less life threatening than the baby`s.
What You Can Do
Prenatal visits during late preg-nancy ascertain the baby`s presentation and posi-tion. Get to know of them. Most babies assume their birth positions in thirty-four to thirty-six weeks. Some turn later, even sometimes during labor. If the baby is still in breech at thirty-sixth week, you may try the simple maneuver called "breech-tilt". This may induce your baby to turn. This maneuver requires you to tilt your body so that your hips are raised higher than your head. You achieve this by lying on your back, bending your knees so that your feet are flat on the floor. Lift your pelvic region by about ten to fifteen inches above your head by pressing with your feet. Slide in enough cushions to support your buttocks to help you maintain this position. Relax your abdominal muscles and stay in the position for ten minutes. Try this at least three times a day, specially when the baby is active. You should try this position on empty stomach and bladder. This causes the unborn child`s head to press into the fundus, consequently the baby will try to move into a more comfortable position. Please note that this technique may not work. Still, since the technique does not have any adverse effect, there is no harm trying it.
Managing Breech Medically
Breech presentation is tackled by various means such as: external version, vaginal birth, and cesarean birth.
1. External version: This method involves manually inducing the baby to the head down position. Your physician gently presses and pushes on the baby through your abdomen; he may also use some drug for uterus relaxation. This procedure is sometimes risky since it may result in placenta separation and cord entanglement. The baby needs to be carefully monitored through the process. The method may or may not work and sometimes that baby may again revert to its breech presentation. Any case, reports suggest that this method is highly successful when performed by experts.
2. Vaginal or C Section: Each breech presentation should be carefully evaluated before opting for cesarean delivery. The parameters the doctor considers are size, gestational age, the type of presentation, pelvis size etc. Also a vaginal breech birth is attempted, if and only if the mother has had a previous vaginal birth. A doctor may opt for vaginal birth for a breech presentation when the baby weighs less than eight pounds, is in a frank breech presentation with a well-flexed head. Even then the situation needs to be carefully monitored and a C section may be performed if medical problem occurs. Therefore, cesarean birth rate of breech is very high.
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