LESSON PLAN ON

PROLONGED LABOUR

SUBMITTED TO,

PROF.DR .Manju Bala Dash

HOD DEPT. OF OBG

SUBMITTED BY,
MTPG & RIHS
Madhubala.C
M.Sc nursing II nd year
MTPG & RIHS
NAME OF THE STUDENT TEACHER : Madhubala.C

NAME OF THE EVALUATOR : Prof.DR. Manju Bala Dash

TOPIC : Prolonged labour

GROUP OF STUDENTS : Bsc (N) 1V year

DATE & TIME :

SUBJECT : Obstetrics & Gynecology

DURATION :

METHOD OF TECHING : lecture cum discussion

VENUE : Bsc (N) IV year class

AV AIDS : Blackboard, PPT, and pamphlet

PREVIOUS KNOWLEDGE : Students have previous knowledge about physiology of normal labour
GENERAL OBJECTIVE:

At the end of the class students will be able to gain in-depth knowledge regarding obstetric shock and develop a desirable
attitude and skills while taking care of mother with obstetric shock.

SPECIFIC OBJECTIVES:

At the end of the class students will be able to,

1. Define prolonged labour

2. write down the causes of shock?
3. identify the pathophysiology of shock ?
4. describe the classification of shock?
5. list down the clinical manifestations of shock?
6. enlist the diagnosis of shock?
7. explain the management of shock?
8. frame the nursing diagnosis for shock?
9. enumerate the complications of shock?
SL. SPECIFIC AV
NO TIME TEACHER LEARNERS AIDS
OBJECTIVE CONTENT EVALUATION
ACTIVITY ACTIVITY
1. 1 mnt Introducing the INTRODUCTION Introducing Answering Black Can anyone
topic Good morning mam and students, I am going to deal topic board guess the topic
about an important topic. Which is significant in obstetrics
“ prolonged labour”

2 2mnt To define shock DEFINITION Explaining Listening PPT Define shock?

& taking
The prolonged labour is defined when the
notes
combined duration of the first and second stage of labour
is more than the arbitary time limit of 18 hours. Labour is
considered prolonged when the cervical dilatation rate is
less than 1cm/hr and descent of the presenting part is
<1cm/hr for a period of minimum 4 hours observations.
It is calculated from mother’s subjective estimate of
onset of true labour.
 Prolonged latent phase: the latent phase is from
onset of regular painful contraction with cervical
dilatation upto 4cm. If cervix is not dilated beyond
4cm for 8 hours of regular contraction is considered
as prolonged latent phase.
 Prolonged active phase: the active phase is period
from cervical dilatation 4-10cm. Regular painful
contractions with cervical dilatation more than 4cm
last longer than 12 hour is considered as prolonged
active phase. If the cervical dilatation arrests more
than 2 hours is considered as abnormal.
 Cervix is fully dilated and woman has urge to push
but no descent is called prolonged expulsive phase.
 The second stage is considered prolonged if it lasts
for more than 2 hours in primigravida and 1 hours in
multipara.
3 2mnts To write down CAUSES Explaining Listening PPT List down the
the causes of & & causes of
shock First stage: failure to dilate cervix is due to- Asking Answering hypovolemic
questions
i. Fault in power:- abnormal uterine contraction such as shock?
uterine inertia or hypotonic uterine dysfunction
(common), incordinate uterine contraction or hypertonic
uterine dysfunction.
ii. Fault in the passage:- contracted pelvis, cervical
dystocia, pelvic tumour or even in full bladder, minor
degree of pelvic contraction.
iii. Fault in the passenger:- malposition (OP) and
malpresentation (face, brow), congenital anomalies of the
fetus (hydrocephalus), deflexed head.
iv. Others:- injudicious (early) administration of
sedatives and analgesic before the active labour begins.

Second stage
1. Fault in power:- uterine inertia, inability to bear
down, epidural analgesia, constriction ring.
2. Fault in the passage:- CPD, Contracted pelvis,
android pelvis, soft tissue pelvic tumour, undue
 resistance of the pelvic floor or perineum due to
spasm or old scarring.
3. Fault in the passenger:- malposition,
malpresentation , big baby, congenital
malformation of the baby.

4. 3mnts To identify the SIGNS AND SYMPTOMS Asking Answering PPT What is stage
pathophysiology question II of shock?
 Labor extend for more than 18 hours
of shock
 The rate of cervical dilatation is less than 1cm/hour
in primigravida and less than 1.5 cm/hour in
multipara in first stage of labor.
 There may be slow descent of head or non descend
of presenting part even after full dilatation of cervix.
 Patient looks exhausted and distressed
  Pain may be more on the radiating to the thighs
4. 3mnts rather than within abdomen due to pressure on Explaining Listening PPT What is stage
To identify the muscle and ligaments. & writing II of shock?
pathophysiology  Pulse rate often high notes
of shock  The uterus is tender on palpation does not relax fully
between contraction.
 Variable degree of moulding and caput formation is
cephalic presentation.
 Fetal distress may develop.
 Membranes may or may not rupture.
 Ketoacidosis may develop due to prolong
starvation.
5 3mnt To describe the Explaining Listening Black What is septic
DIAGNOSIS
classification of board shock
 History of prolonged labour
shock &
 Abdominal examination PPT
 Per vaginal examination
 Partograph
 Intranatal imaging (radiography, CT or
MRI) is of help in determining the fetal
station and position as well as pelvic shape
and size.

5 3mnt To describe the Risk of prolonged labour : Explaining Listening PPT What is septic
classification of & shock?
Fetal risk
shock taking
• Hypoxia due to decreased uteroplacental
notes
circulation.
• Intrauterine infection
• Intracranial stress or hemorrhage following
prolonged stay on perineum
• Increased operative delivery
• Increased risk of perinatal loss
Mother risk
• Maternal distress
• Intrauterine infection
• Trauma and injuries in birth canal eg cervical
tear, rupture of uterus
• PPH
• Postpartum infection or puerperal sepsis
• Subinvolution

FIRST STAGE:
First stage of labor is considered prolonged when the
duration is more than 12 hours.
The rate of cervical dilatation is <1 cm/hr in a primi and
<1.5 cm/hr in a multi. The rate of descent of the
presenting part is <1 cm/hr in a primi and <2 cm/hr in a
multi.
In a partograph (WHO-1994), the labor
process is divided into:
(i) Latent phase that ends when the cervix is 4
cm dilated.
 (ii) (ii) Active phase—starts with cervical
dilatation of 4 cm or more. Cervix should
dilate at least 1 cm/h in this active phase.
Cervical dilatation rate (cervicograph) is plotted in
relation to alert line and action line.
Alert line starts at the end of latent phase (4 cm cervical
dilatation) and ends with full dilatation of the cervix (10
cm) in 6 hours (1 cm/h dilatation rate). The action line is
drawn 4 hours to the right of the alert line.
An interval of 4 hours is allowed to diagnose delay in
active phase and then appropriate intervention is done.
Labor is considered abnormal when cervicograph crosses
the alert line and falls on zone 2 and intervention is
required when it crosses the action line and falls on zone
3.
Partograph can diagnose any dysfunctional labor early
and help to initiate correct management.
Disorders of the active phase: Active phase disorders
may be divided into:
(A) protraction and
(B) arrest disorders.
(A) Protracted active phase: When the rate of cervical
dilatation is <1.2 cm/h in a primipara and <1.5 cm/h in a
multipara.
A protracted active phase may be due to:
(i) inadequate uterine contractions,
(ii) cephalopelvic disproportion,
(iii) malposition (OP) or malpresentation (brow)
(iv) regional (epidural) anesthesia.

(B) Arrest disorder: Arrest of dilatation is defined when

no cervical dilatation occurs after 2 hours in the active
phase of labor. It is commonly due to inefficient uterine
contractions. No descent for a period of more than 2 hour
is called arrest of descent. It is commonly due to CPD.
Secondary arrest is defined when the active phase of
labor (cervical dilatation) commences normally but stops
or slows significantly for 2 hours or more prior to full
dilatation of the cervix. It is commonly due to
malposition or CPD.
SECOND STAGE:
Mean duration of second stage
is 50 minutes for nullipara and 20 minutes in
multipara. Prolonged second stage is diagnosed if the
duration exceeds 2 hours in nullipara and 1 hour in a
multipara when no regional anesthesia is used. One hour
or more is permitted in both the groups when regional
anesthesia is used during labor (ACOG).
Disorders of the second stage:
(i) Protraction of descent is defined when the
descent of the presenting part (station) is at
less than 1 cm/h in a nullipara or less than 2
cm/h in a multipara.
(ii) Arrest of descent is diagnosed when no
progress in descent (no change in station) is
observed over a period of at least 2 hours. It
may be due to one or a combination of several
underlying abnormalities like CPD,
malposition (OP), malpresentation,
inadequate uterine contradictions or
asynclitism.
SL. SPECIFIC AV
NO TIME TEACHER LEARNERS AIDS
OBJECTIVE CONTENT EVALUATION
ACTIVITY ACTIVITY
6 3mnt To list down the DANGERS
clinical Fetal: PPT
manifestations The fetal risk is increased due to the What are
combined effects of: Explaining
of shock Listening clinical
(1) Hypoxia due to diminished uteroplacental &
circulation, especially after rupture of the & manifestations
asking question
membranes, Answering of
(2) Intrauterine infection, hypovolemic
(3) Intracranial stress or hemorrhage
shock
following prolonged stay in the
perineum and/or supermoulding of the head,
(4) Increased operative delivery. Prolonged
second stage of labor is often associated with
variable and delayed decelerations .
Scalp blood pH estimations show fetal acidosis.
All these result in increased perinatal morbidity
and mortality.
Maternal:
There is increased incidence of:
(1) distress
(2) chorioamnionitis,
(3) Postpartum hemorrhage,
(4) trauma to the genital tract—concealed (undue
stretching of the perineal muscles which may be
the cause of prolapse at a later period) or
revealed such as cervical tear, rupture uterus,
(5) increased operative delivery (vaginal
instrumental or difficult cesarean),
(6) puerperal sepsis,
(7) subinvolution. The sum effects of all these
lead to increased maternal morbidity and also
increased maternal deaths.

TREATMENT :
Careful evaluation is to be done to find out:
(1) cause of prolonged labor
(2) effect on the mother,
(3) effect on the fetus.
In a nulliparous patient, inadequate uterine
activity is the most common cause of primary
dysfunctional labor. Whereas in a multiparous
patient, cephalopelvic disproportion (due to
malposition) is the most common cause.
Preliminaries: In an equipped labor ward,
prolonged labor is unlikely to occur in modern
obstetric practice. But cases of neglected
prolonged labor with evidences of dehydration
and ketoacidosis are admitted not infrequently to
the referral hospitals in the developing countries.
Correction of ketoacidosis should be made
urgently by rapid intravenous infusion of
Ringer’s solution.
Definitive treatment:
First stage delay: Vaginal examination is done
to verify the fetal presentation, position and
station. Clinical pelvimetry is done.
If only uterine activity is suboptimal,
(1) amniotomy and/or oxytocin infusion is
adequate,
(2) effective pain relief is given by intramuscular
pethidine or by regional (epidural) analgesia.
For the management of secondary arrest,
especially in multipara one should be very
careful to use oxytocin,
(3) cesarean section is done when vaginal
delivery is unsafe (malpresentation, malposition,
big baby or CPD).
Second stage delay—Short period of expectant
management is reasonable provided the FHR
(electronic monitoring) is reassuring and vaginal
delivery is imminent. Otherwise appropriate
assisted delivery, vaginal (forceps, ventouse) or
abdominal (cesarean) should be done. Difficult
instrumental delivery should be avoided.
6 3mnt To list down the Nursing management:
clinical PPT What are
 Principles of care for a mother in
manifestations clinical
of shock labour are continued as for normal Explaining
manifestations

birth but with particular attention to Listening of late stage of

hypovolemic
the following :
shock
 Informed choice and consent to
treatment
- the midwife should give as much as
information available to ensure that the
couple understand the event and to obtain
consent to all aspect of treatment.
 Psychological support
- give emotional support by giving
information that ensure the woman
understands events, feels free to ask
questions and is aware on how labour is
progressing . Besides that, following any
procedures, the midwife should provide
feedback & verbal reinforcement.
- offer Husband Friendly to patient to
reduce her anxious.
 Communication
- communication between personnel
with liaison between the midwifery,
obstetric & pediatric services should be
clear to ensure that support and care
available as needed.
 Comfort & Cleanliness
- general hygiene is important,
especially where the membranes have been
ruptured. Prolong contact with moisture can
also give rise to tissue damage and soiled
pads & bed linen should be changed as
necessary
- wet the patients lips as a comfort to
patient
 Position
- Encourage the mother to change the
posture other than supine to fasten the
progress of labour
 Observations
- temperature should be taken every 4
hours as infection may develop where there
has been prolonged rupture of membrane
- pulse and blood pressure are
recorded hourly, or more frequently if the
women’s condition requires.
 All relevant observations are noted &
should be recorded on the partogram or
written in the client’s record.
 Empty bladder
- in all stages of labour, the midwife
should make sure that the women is able to
pass urine but if she is not able to, then the
women must be catheterized in order to
help the descent of presenting part
 Assessment of progress in
prolonged labour
- asses the progress of contraction to
detect for hypotonic uterine contraction
which will cause prolong labour
- asses on descent per abdomen via
abdominal palpation
 - vaginal examination is carried out
usually on a 4 hourly regime.
- progress is noted in terms of
increasing dilation, along with the
consistency of the cervix to the presenting
part.
- position of sagittal suture is also noted
where in caput or moulding , position and
station difficult to asses as it masks the
sutures & fontanelles
- descent of the presenting part also
noted to see the labour progress.
the colour of the amniotic fluid needs
to be noted and if meconium is present this
should be reported.
 The midwife should use the
partograph in early detec tion & responsible
for letting the DR know asap when some
abnormality has arisen, & this includes
prolonged labour.
 Fetal well being
- monitor GTG continuously to
determine fetal distress
- FHR (tachycardia /
bradycardia)
- presence the accelaration is
normal.
- presence of decelaration which
is abnormal
 - baseline variablity where loss
of this variability may indicate fetal
compromise.
- the presence of meconium- stained
liquor and an abnormal FHR tracing is
suggesive of fetal hypoxia.
- A pediatrician should be present at
the birth to prevent aspiration of meconium.
 Any maternal or fetal distress is
immediately reported to the DR &
these conditions are treated by the
midwife, pending the arrival of the
DR.
 preparations are made foe either a CS
if the first stage of labour is
prolonged, or for an instrument
 delivery or CS in the second stage of
labour
- Caesarean section is indicated in:
– Failure of the above measures.
– Disproportion.
– Malpresentations not amenable
for vaginal delivery.
– Contraindications to oxytocin.
– Foetal distress.
 After prolonged labour, the baby is
observed in ‘ high care ’ till the
condition is satisfactory to stable.
Change of posture in labor other than supine to
increase uterine contractions, emotional support,
avoidance of dehydration in labor and use of
adequate analgesia for pain relief.
SL. SPECIFIC AV
NO TIME TEACHER LEARNERS AIDS
OBJECTIVE CONTENT EVALUATION
ACTIVITY ACTIVITY
6 3mnt To list down the Nursing diagnosis:
clinical PPT What are
 Risk for maternal injury related to maternal
manifestations clinical
fatigue. Explaining
of shock manifestations
 Risk for fetal injury related to Listening of Neurogenic
cephalopelvic disproportion and other fetal shock
risk factors.
 Risk for fluid volume deficit related to
vomiting and restricted oral intake.
 Ineffective individual coping related to
situational crisis evidenced by
verbalization.
SUMMARY

So far we have seen about prolonged labour , its causes, signs and symptoms, diagnosis, risk factors, prolonged labour in first stage and
second stage labour , dangers of maternal and fetal, treatment, nursing management and nursing diagnosis.

CONCLUSION

Till now we have seen in detail about prolonged labour and its significance of management . I hope that you all understood it well and
gained knowledge.

ASSIGNMENT

Write about the prevention of prolonged labour .

EVALUATION

Time: 5 minutes

Marks: 5 marks

1. Listdown types of shock? (2)

2. Write any three clinical manifestation of hypovolemic shock? (3)
REFERENCE

TEACHERS REFERENCE

1. Dutta D.C Text book of Obstetrics –Including perinatology and Contraception,6th Edition (2004), New central
book Agency (Kolkata) Pg. No.463-466.
2. Basavanthappa B.T Essentials of Midwifery & Obstetrical, Jaypee Publications (New Delhi) Pg.No.240-245.
3. Lowdermilk & Perry “Maternity Nursing”, 6th edition Published by Mosby (Philadelphia), , page no: 323-
324.
4. Annamma Jacob, “A Comprehensive Textbook of Midwifery and Gynecological Nursing” Jaypee Brothers
Medical Publishers (P) LTD, Third Edition, 2012. Page No: 501-505

STUDENT REFERNCE

1) Dutta D.C Text book of Obstetrics –Including perinatology and Contraception,6th Edition (2004), New central
book Agency (Kolkata) Pg. No.463-466.
2) Basavanthappa B.T Essentials of Midwifery & Obstetrical, Jaypee Publications (New Delhi) Pg.No.240-245.