THE GENERAL METHOD FOR DELAY IN LABOUR

Here is the general method for delay in labour. If the presenting part has not only failed to descend, but there have also been these signs, labour is not only delayed, it is also obstructed: severe moulding and caput, fetal distress, a stretched lower segment, bloody urine, etc. If so, see Section 18.3.

DELAY IN THE LATENT PHASE (primips and multips)

The latent phase is prolonged, if a patient who was ’admitted in labour’ has not reached the active phase after 8 hours. First distinguish ’false labour’ and a truly prolonged latent phase.

False labour:

her membranes are still intact, a nullip’s cervix remains long and closed (or just admits a finger tip), a multip’s cervix is not effaced (even though it may be 1 or 2 cm dilated). Explain that she is not in labour, and send her home if she wishes. If she insists that she feels painful contractions give her pethidine 100 mg, let her sleep, and then discharge or review her.

Truly prolonged latent phase:

Her cervix is completely effaced, but remains stationary at about 2 cm. Or it effaces and dilates very slowly. Either, (1) Sedate her with pethidine 100 mg, repeated if necessary, and wait. Or, (2) let her walk about. Or, (3) rupture her membranes and give her an oxytocin drip.

DELAY IN THE ACTIVE PHASE primips

If a primip’s progress line approaches the action line, she may have primary uterine inertia, or there may be some mechanical reason for it. Section her if: (1) She has gross CPD (head 4/5 above the brim and marked moulding). (2) A malpresentation (breech, transverse lie, face, or brow, etc.). (3) Fetal distress (M 20.4, M 21.3). If she has none of these things, manage her actively to decide if she has doubtful CPD, or no CPD. Manage her like this.

(1) Correct her dehydration and ketosis. Give her a drip of 5% dextrose.

(2) Provide adequate analgesia (A 2.9, M 18.15). Either give her a lumbar epidural block (A 7.2), or give her pethidine 100 mg and promethazine 25 mg, both intramuscularly.

(3) If you are sure she is in labour (that is her cervix is dilated 3 cm or more) and her membranes are not already ruptured, rupture them.

(4) Stimulate her uterus with oxytocin. Add 5 units of oxytocin to 500 ml of 5% dextrose, and start at 10 drops a minute. Increase the rate of the drip by 10 drops a minute at half-hourly intervals, until she is having contractions lasting 45 to 60 seconds at a frequency of 3 to 4 in 10 minutes. Make the first increment to 20 drops a minute, and half an hour later to 30 drops a minute. As soon as she has good contractions, don’t increase the speed of the drip any more.

(5) Monitor her progress and her baby’s condition carefully. Monitor his heart and watch for signs of fetal distress, especially slowing of the fetal heart (meconium staining of the liquor is common, and is an unreliable sign, M 20.5).

Decide how you are going to deliver her within 6 hours of starting the the oxytocin drip. Section her if any of these things happen, they are probably all signs of severe CPD: (1) There is fetal distress. (2) At the end of 6 hours she is still dilating less than 1 cm per hour, and the head is not descending. (3) It remains high, with moulding.

DELAY IN THE ACTIVE PHASE multips

If a multip’s progress line approaches the action line, this is serious, and you will need to assess her carefully. Don’t try to stimulate her uterus with oxytocin, unless you are absolutely sure there is no CPD (see Section 18.4a). This is difficult to be sure about, and if you are wrong, and there is CPD, her uterus may rupture. One contributor advises no oxytocin for multips!

If she is in definite labour (her cervix is 3 cm or more) and her membranes have not already ruptured, rupture them. If you are in doubt, observe her for 2 more hours with adequate analgesia, and then reassess her. Feel her contractions yourself. She may progress to full dilation even when there is major CPD. You can only detect this by finding severe moulding and caput, with failure of the head to descend, and delay (more than 20 minutes in the second stage).

CAUTION! Some mothers have 6 or 8 normal labours, and then need section for CPD with their next pregnancy.

DIFFICULTIES WITH DELAY IN LABOUR

If a patient is referred because of DELAY IN THE LATENT STAGE (M 20.7), look carefully for hidden CPD. If there is no CPD, rupture her membranes, and give her an oxytocin drip. Clinics should refer these cases, because CPD is not easy to recognize. Provided there is a vertex presentation, it is always worth rupturing the membranes and waiting a little to see what happens. CPD is almost impossible to diagnose when the membranes are intact.

If there is FETAL DISTRESS: if the is having an oxytocin drip, stop it; turn her onto her left side, do a vaginal examination to exclude prolapse of the cord, make sure she is she is adequately hydrated and give her oxygen.