Subject:         Prolonged Labor/Failure to Progress

POLICY:         Prolonged labor may occur when a primigravida has a long latent phase of labor and with a primagravida or multigravida woman experiences a failure to continue dilation while in active labor.  Prolonged labor may predispose the mother and baby to risks including maternal exhaustion, fetal distress and chorioamnionitis.  The birth attendant minimizes the likelihood of risks by careful assessment, helping to establish a good maternal labor pattern and limiting length of time in non productive labor patterns.  A Physician will be consulted if the labor lies outside of the guideline parameters.

GUIDELINES: 1. Clients will come to the center for evaluation when they have lost a night of sleep or they are feeling maternal tiredness/exhaustion regardless of stage of labor.

2. Electronic fetal monitoring will be utilized for a 15 – 20 minute strip when mother is deemed to be in a prolonged labor pattern.

3. When a client is in ACTIVE LABOR a physician will be consulted if there is less than one centimeter of cervical progress in three to five hours.

4. When a client is in SECOND STAGE labor a physician will be consulted if there is no progress in two hours for a primagravida and one hour for a multigravida.

5. A Physician will be consulted if mother requests consult of transfer

6. A Physician will be consulted if additional risk factors present:

·         Signs of maternal exhaustion

·         Maternal temperature of 100.4 or above

·         Moderate to thick meconium staining in the fluid

·         Persistent maternal and/or fetal tachycardia or other signs of fetal distress.

·         Prolonged ROM as per PROM protocol.

PROCEDURE: 1. Assess for stage of labor – active labor is defined as being 4-5 centimeters and contraction pattern of three contractions within ten minutes.  Second stage labor is defined as complete dilation and urge to push.

2. Assess Maternal and Fetal well being:

·         Sterile Vaginal exam for cervical effacement, dilation and pelvimetry

·         Size and position of fetus

·         Fetal heart tone pattern, electronic fetal monitoring for 15-20 minutes

·         Status of membranes

·         Length, strength and intensity of contractions

·         Hydration status of mother

·         Assess status of bladder and consider catheterization

3. If in latent phase labor consider medication induced rest

4. If in active phase labor consider the following methods for encouraging a more productive labor pattern:

·         Position changes (suggestions found at: http://spinningbabies.com)

·         Hydrate mother with oral or IV fluids

·         Nipple stimulation

·         “Psychological stimulation” (reassure mother and have a positive attitude)

·         Change environment – i.e.: walk

·         Encourage relaxation with shower, bath, massage

·         Herbal/homeopathic stimulation

·         Chiropractic/acupuncture stimulation

·         Utilize all methods that mother is willing to try before transport decision is made. Many women will be more responsive to more support to encourage labor.

5.  If in second stage labor the following assessments need to be made:

·         Maternal nourishment status

·         Maternal hydration status

·         Bladder status

6. If in second stage labor consider the following methods for encouraging a more productive descent pattern:

·         Position changes, i.e.: squat, stand, supine, birth stool, hands and knees, in Jacuzzi (suggestions found at: http://spinningbabies.com)

·         Hydrate mother with oral IV fluids

·         Vaginal exam with rectal pressure

·         Bladder catheterization

·         Discuss fears and instill confidence

·         Change method of encouragement

·         Assist in rotational of fetal head with maternal position changes and manual rotation

·         Shower or bath for change in environment

·         Contraction stimulation utilizing nipple stimulation, herbal or homeopathic stimulation

Prolonged Latent Phase

Failure to Progress/Protraction disorder (active phase)

Arrest Disorder

Diagnosis

Nullipara: >20 hours

Multipara: >14hours

Nullipara: >1.5cm/hour dilation

<1 cm/hour descent

Multipara:

<1cm/hour dilation

<2 cm/hour descent

Dilation: 3 hour no progress

Descent 1 hour no descent

Contributing Factors

Prodromal labor

Uterine dysfunction

Maternal fear

Dehydration

Fetal Malposition

Maternal Fear

Dehydration

Maternal Exhaustion

Uterine dysfunction

CPD

Fetal Malposition

Maternal fear

Dehydration

Maternal Exhaustion

Uterine dysfunction

CPD

Treatments

Rest

Support and Stimulate

Support and Stimulate

Expected Outcomes

90% progress to active phase

90% progress to complete dilation

90% progress to birth

Delivery Prognosis

Vaginal Delivery

Vaginal Delivery or transfer

Vaginal Delivery or transfer

Fetal Prognosis

No Risk

Slightly increased risk

Triple risk with Arrest disorder