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Prolonged Labor

Prolonged Labor

Labor that lasts more than 24 hours is by definition called prolonged labor.  The exact time of the onset of labor is often hard to diagnose.  The best definition of the onset of labor is the time at which the woman has contractions that lead toward the birth of her baby.  
Friedman's Graph
Friedman made a graph to measure the progression of labor.  Most midwives realize that each woman's labor will be unique and that because of the many variables of each woman's labor and delivery, this graph must be used with common sense. There are too many differences among women to hold fast to this graph in every situation.

According to Friedman's Graph:
The latent phase of labor begins with the onset of labor and lasts until the beginning of the active phase of labor.  Cervical dilation averages 0.35 cm per hour.  At the end of the latent phase the cervix is dilated to about 3 cm.  The average length of the latent phase in primigravidas is 8.6 hours with an upper limit of 20 hours.  The average length for multigravidas is 5.3 hours with an upper limit of 14 hours.  A prolonged latent phase does not mean that the active phase will also be prolonged.

The active phase begins at the end of the latent phase and lasts until full dilation of the cervix. The average length of the of the active phase in primigravidas is 5.8 hours with an upper limit of 12 hours.  The rate of cervical dilation is 1.2 to 6.8 cm per hour.  The average length for mulitgravidas is 2.5 hours with an upper limit of 6 hours.  The rate of cervical dilation is at least 1.5 cm per hour.

The maximum duration of the first stage of labor in primigravidas is 28.5 hours, with a maximum second stage of 2.5 hours.  In multigravidas the maximum duration of first stage is 20 hours with a maximum second stage of 50 minutes.

Factors

There are many different reasons that a labor may be prolonged.
*  Fetopelvic disproportion.  This prevents the baby from moving down into the birth canal.
*  Malpresentations:
    Face or Brow Presentation
    Posterior Presentation
*  Inefficient uterine action and the inability of the cervix to dilate smoothly and rapidly.               Weakness of uterine action is called hypotonic uterine dysfunction.
*  Excessive analgesia
*  Primigravidity.  First time mothers have longer labors.
*  PROM.  If a woman's membranes rupture before labor has begun it may take longer to             establish an active labor pattern.
*  Unripe cervix at the beginning of labor.

Risks

*  Maternal risks include:  uterine atony, hemorrhage, infection, exhaustion, and shock.
*  Fetal risks include:  distress, asphyxia, injury, and infection.  Fetal well-being needs to be         monitored.

Prevention of Prolonged Labor

*  Good prenatal care reduces the incidence of prolonged labor.  The baby's position is checked     for vertex presentation with good head flexion.
*  False labor is treated by rest.
*  Labor is not induced or forced when the cervix is not ripe.  This includes natural labor i             inductions, rupture of membranes, or drugs.
*  The woman should try to be well rested at the beginning of her labor. If she knows she is in     early labor, she should not wear herself out.  A tired uterus will not contract as efficiently.

Assessment of Labor

*  The woman's progress is monitored and assessed regularly.  
*  The woman's general condition is observed for signs of fatigue:
    hydration, energy, nourishment, temperature, pulse.
*  The position of the baby and the presenting part must be accurately diagnosed.                       Engagement and station should be noted.
*  If there is failure of descent, the cause needs to be determined.  Is it the cervix, the pelvis,       the fetus, the size of the head, weak uterine contractions, etc.?
*  The uterine contractions are assessed for strength, efficiency, frequency, length, interval,         and changes.
*  Pelvic adequacy and signs of CPD are assessed.

Management of Prolonged Labor

*  Encouragement is provided for the laboring woman.  She will need extra support to get           through a long labor.
*  Hydration is maintained.
*  The woman may eat and drink as desired during early labor.
*  The bladder is emptied every hour.  The urine is checked for ketones every 4 hours to make    sure she is not showing signs of exhaustion.
*  Vaginal exams are performed conservatively under sterile conditions.
*  The condition of the baby is monitored by checking FHT's and watching for meconium.  The     baby is closely monitored for signs of stress.

Natural Remedies

Many problems can be resolved by creating an atmosphere for the mother in which she feels comfortable and safe.  Studies have shown that animals who are scared or otherwise feel unsafe have dysfunctional labors.
* A quiet, nonstressful environment will help the woman to move into a natural labor.
*  Bright lights can cause stress.  Dim lights or candles are very soothing.
*  Positive, comforting words will help her to relax.
*  A warm bath or shower can help her to relax.  Putting women in water works very well.
*  Going for a walk may help.  This will often help the baby's head to be better applied to the       cervix and increase the strength and efficiency of contractions.
* Try different positions to see which position works best for helping labor to progress.   
* Nipple stimulation releases natural oxytocin. This works best if both nipples are stimulated at the same time.  The nipples should be massaged and pulled on in imitation of how a baby nurses.  The nipples are massaged until a contraction starts and then massage is stopped.
When the contraction is over massage begins again.
*  Castor Oil can be used if the woman is having a hard time moving into active labor.    The woman should eat a high carbohydrate meal.  Two hours later she should drink 2 - 3 oz. of castor oil mixed with 6 oz. of orange juice and 1/2 tsp. of baking soda. This concoction has a very high rate of success if the cervix is at least 2 cm dilated and 50% effaced.
*  Herbs:
Oil of Primrose - rubbed directly on the cervix encourages opening and softening of the cervix.
Emotional Aspects
It is not uncommon to find an emotional reason that is stalling a woman's labor.  If these emotional aspects can be addressed it will often resolve the dysfunctional labor.  



Sources:

Davis, Elizabeth, Heart and Hands, Celestial Arts, Berkeley, CA, 1987, pp,93-97
Oxorn, Harry, Human Labor and Birth, Appleton and Lange, Norwalk, CT, 1986 pp757-770
Weed, Susun S., Wise Woman Herbal for the Childbearing Year, Ash Tree Publishing, Woodstock, NY, 1986
Varney, Helen, Nurse-Midwifery, 2nd Edition, Jones and Bartlett Publishers, Sudbury,  MA, 1987 pp333-338
Bobak & Jensen, Maternity and Gynecological Care, 5th Edition, Mosby Year Book, Inc., St. Louis MI, 1993   pp. 1052-1057
Buckley, Kathleen, and Nancy W. Kulb, Handbook of Maternal-Newborn Nursing, Delmar Publishers, Inc., Albany, NY, 1983, pp. 221-295

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