ical intervention. All factors for each individual woman, including her wishes, should be taken into account.
Sometimes slow progress is more serious and indicates a significant problem. Usually with the passing of time, a skilled midwife will identify and refer, those labours truly running into trouble, and avoid unnecessary intervention in labours which are simply progressing slowly but surely.
Current parameters for ‘normality’ have been defined and imposed on labouring women by obstetricians from a time where practice ‘served organisational and management priorities’ rather than evidence (Royal College of Midwives (RCM), 2005) and when the views of women were not considered important. Advocates of active management claim shorter labours are better; however, evidence is contradictory and benefits of a slightly shorter labour remain unproved. Diagnosis of slow progress often marks the transfer from ‘normality’ and ‘midwifery care’ to one of ‘obstetric management’ (Cluett et al., 2004). This sometimes highlights cultural friction between two different philosophies of care and illustrates the powerlessness of midwives and child–bearing women to challenge obstetric control in ‘normal’ birth. Debate continues over conservative versus active management in the politics of the medicalisation of birth (Walsh, 2000a; Neilson et al., 2003; Cluett et al., 2004; RCM, 2005; Albers, 2007).
In the quest for preventing long labours, some of the direct iatrogenic effects of the medical model of care – restricted mobility (Gupta et al., 2000), enforced fasting (Johnson et al., 2000), lack of continuity of carer or support in labour (Hodnett et al., 2003) and epidural anaesthesia (Dickersin, 2000) have been overlooked by obstetricians as direct causes of labour dystocia. In ignoring traditional, proven and simple preventative measures, clinicians have instead carried out interventions including routine vaginal examinations, artificial rupture of the membranes (ARM) and oxytocics to ‘manage’ this fairly common problem with little regard for the woman’s individual circumstances or wishes (Albers, 2007).
Incidence
- Slow progress (dystocia) in labour affects mainly primiparas – around 20% (Cluett et al., 2004), however, dystocia is open to interpretation and statistics vary between different practitioners and units (Crowther et al., 2000).
- Outcomes (NHS Maternity statistics, 2007):
- Twoout of threewomenwith a prolonged first stage have an emergency caesarean (CS).
- Two out of three women with a prolonged second stage have an instrumental delivery.
- Twoout of threewomenwith a prolonged first stage have an emergency caesarean (CS).
- Approximately half of women judged to have a ‘slow’ labour progress equally well whether or not oxytocic drugs are used (Keirse et al., 2000).
Facts
- Early labour assessment and reassurance by midwives (ideally at home) reduces subsequent interventions, time spent on labour ward, augmentation, analgesia use and epidurals, and women are more likely to report an improved birth experience (McNiven et al., 1998; Walsh, 2000a; Lauzon & Hodnett, 2002).
- During labour women appear to have an altered perception of time and events (RCM, 2005).
- Anxiety and environmental stressors have a negative physiological effect on labour progress.
- Encouraging women to mobilise and remain upright during labour enhances contractions and reduces dystocia.
Prolonged labour
Active management of labour
‘Active management of labour has accumulated a number of eminent critics, who assert that the framework for its basic tenets are based on unscientific assumptions’ (Regan, 1998).
Active management was claimed to prevent CS in women whose progress was deemed ‘slow’. This package of care includes ARM, early recourse to intravenous (IV) oxytocin infusion, continuous CTG, epidural anaesthesia and one-to-one midwifery care.
Neilson et al. (2003) state that randomised studies evaluating the efficacy of the whole package of active management are extremely rare. Evidence of any benefit is often contradictory and meta-analysis of the randomised clinical trials on specific components of active management shows that:
- Active management shortens labour by on average 1–2 hours.
- There is no clinical evidence to support any general benefits from a shorter labour (RCM, 2005).
- Claims that active management reduces the instrumental or CS rate are unsubstantiated (Neilson et al., 2003).
- The one consistent reproducible effective component of active management that is often forgotten in debates is the simple, non-invasive effectiveness of continuous one-to-one midwifery support in labour (Thornton & Lilford, 1994). It has been proved to shorten labour, reduce intervention and improve neonatal outcomes and maternal satisfaction (Hodnett et al., 2003; Neilson et al., 2003). This element of active management has consistently been ignored by obstetricians, managers and NHS policy makers.
- Routine ARM has minimal effect length of labour duration, although if used following a diagnosis of slow progress, ARM may improve subsequent labour progress and duration in nulliparous women (Smyth et al. 2007).
- Oxytocin augmentation does not improve CS rates, operative vaginal delivery rates or neonatal outcome, and its effect of length of labour remains inconclusive (Thornton & Lilford, 1994; Keirse, 2000).
- Oxytocin increases pain and the risk of hyperstimulation (Keirse, 2000).
Much of the above evidence has been in wide circulation for over 15 years.
Assessing progress in labour and the partogram
The various methods of assessing progress are described in more detail under ‘Assessing progress in labour’ in Chapter 1.
Midwives use various methods to assess progress including frequency and strength of contractions (Sallam et al., 1999), the woman’s response, external signs, abdominal palpation to assess descent of the presenting part (Stuart, 2000) and vaginal examinations (VEs). VEs monitor, amongst other things, cervical dilatation and are the most commonly accepted method for assessing labour progress although they remain unevaluated by research (Crowther et al., 2000). VEs, contraction frequency and abdominal findings can be recorded on a partogram.
The partogram has evolved from Friedman’s work in the 1950s on mean time limits for cervical dilatation (Walsh, 2000a). It offers an immediate visual impression of the woman’s overall physical condition and has alert and action lines used to record progress. This can be beneficial in hospitals, where midwives may be caring for several women and shifts change regularly. National Institute for Health and Clinical Excellence (NICE) (2007) recommends its use, with a 4-hour action line. However, care may become prescriptive, disregarding the woman’s individual circumstances and wishes.
Observational studies (Buchmann, 2000) and a large Southeast Asian trial by the World Health Organization (WHO, 1994) found the partogram helped clinicians recognise, refer and act on prolonged labour. This reduced augmentation, emergency CS and perinatal mortality (Buchmann, 2000). However, some critics cast doubt on the quality of this prospective WHO study (Neilson et al., 2003) as it introduced other variables alongside the partogram (e.g. intensive staff training and a new labour management protocol which included routine ARM in active labour). Neilson et al. suggest:
‘There is only one reliable way of testing whether an intervention improves outcome and that is with a randomized controlled trial. The research method used and additional variables introduced could have been biased and lays the results open to doubt … Even if the results could be relied upon, one could question how applicable they are in other settings in the developed world where women have access to quality care.’
How slow is too slow?
The ‘latent’ and ‘active’ phases of labour are artificial constructs defined purely for clinical management purposes (Cluett, 2000); assessing labour onset, defining progress and when to intervene remain subjective and inexact, varying between units, hospitals, regions and countries (Crowther et al., 2000).
- Contractions should become regular and progressively stronger, increasing in frequency and duration.
- Cervical dilatation of 0.5 cm/hour (if there are no other fetal or maternal concerns) may lead to fewer unnecessary labour interventions (Crowther et al., 2000) and has increasingly been adopted in midwifery-led care settings and Wales (All Wales Clinical Pathway, 2004) and forms part of NICE (2007) intrapartum guidelines.
- Simkin and Ancheta (2005) describe the importance of additional measures of progress including cervical consistency, thinning and effacement, movement from posterior to anterior and the importance of good cervical application to the presenting part.
- Cervical dilatation of 0.5 cm/hour (if there are no other fetal or maternal concerns) may lead to fewer unnecessary labour interventions (Crowther et al., 2000) and has increasingly been adopted in midwifery-led care settings and Wales (All Wales Clinical Pathway, 2004) and forms part of NICE (2007) intrapartum guidelines.
Obstructed labour
Obstruction is the failure of the presenting part to descend in spite of uterine contractions, manifesting itself ultimately as not slow progress but no progress. Obstruction may be caused by cephalopelvic disproportion (CPD), abnormal lie or presentation, e.g. brow (King et al., 1999). Lack of progress and descent is usually noticeable with the passing of time. What really distinguishes delay from obstruction is the secondary signs and complications that follow.
Early signs of unresolved obstructed labour:
- Prolonged first and/or second stage
- Severe moulding and caput/high presenting part
- >Often fetal heart rate (FHR) abnormalities
- No further descent of the presenting part.
- A rigid retraction band ‘Bandl’s ring’ forms as the lower segment becomes stretched: it can be felt as a transverse ridge across the lower abdomen.
- Bladder damage (often indicated by bloodstained urine).
- Fistulae (usually nulliparous women).
- Ruptured uterus (usually multiparous women).
- Fetal death.
- Maternal shock and sepsis often leading to death. Serious consequences of obstructed labour should never happen where care is adequate (King et al., 1999).
Causes of a prolonged labour
Slow progress can have one or several causes.
Physical causes
- Fetal presentation/position. See malpresentations and malpositions in labour later in this chapter.
- Cephalopelvic disproportion. CPD is not easily predictable but is usually determined during labour if there is lack of descent of the presenting part (Crowther et al., 2000) with increased caput and moulding (King et al., 1999; Neilson, 2003). Predisposing factors include a small woman with a suspected large baby, maternal diabetes, a macrosomic baby and malposition. Previous uncomplicated delivery of a baby of similar weight is the most reliable predictor of pelvic adequacy (Enkin et al., 2000).
- Restricted mobility and the semi-recumbent position. Do midwives cause dystocia? In the UK, three-quarters of women adopt a supine position for labour and birth. This is in part historical and cultural (RCM, 2005) but also due to lack of direction and encouragement from midwives (see also Chapter 1, p. 14).
Upright postures are a simple intervention to ensure adequate uterine contractions preventing dystocia. They open the pelvic outlet by as much as a third (RCM, 2005), reduce the pain felt by women, reduce the duration of second stage (Gupta et al., 2000) the episiotomy rate (Gupta & Hofmeyer, 2004; Nasir et al., 2007) and instrumental deliveries (Roberts et al., 2005; Nasir et al., 2007). Even women with epidural anaesthesia can benefit from adopting non-lying postures (Downe et al., 2004; Roberts et al., 2005).
The RCM (2005) campaign for normal birth acknowledges that midwives are the key to promoting mobility throughout labour and that encouraging the use of gravity-enhancingupright postures will help ensure a straightforward birth and may prevent labour dystocia.
Less common physical causes
Usually the following problems will have been identified and discussed prior to labour:
- Pelvic anomalies: fractured pelvis, women with significant weight-bearing problems, e.g. from lower limb amputation, spina bifida and spinal injury.
- Cervical problems may arise following cervical surgery, e.g. previous cone biopsy. The internal os can feel rough to the touch and the cervix tight and unyielding for a prolonged period (commonly during the latent phase). Simkin and Ancheta (2005) suggest contractions of great intensity may be required to overcome the initial resistance, following which dilatation usually occurs.
Stress response and emotional dystocia
‘Dr. Michel Odent advocates “Zee most important thing is do not disturb zee birthing woman.” I think we know what he means…’ (Lemay, 2000).
- Stress hormones interact with beta-receptors in the uterine muscle to inhibit contractions, slowing labour down (Cluett, 2000). This is most evident in primiparae arriving for the first time on labour ward, where their anxiety response causes their labour to temporarily stop.
- Psychological stress and anxiety can be stimulated by many factors. Environmental stress can be caused by arriving on labour ward with its bright lights, unfamiliar noises and lack of quiet privacy, in addition the staff may be busy; a minority even unsupportive or uncaring. (For more information on preparing a good birth environment see Chapter 1.)
- Some women may have personal anxieties such as fear of pain or childbirth and others may have had a previously traumatic delivery or are victims of childhood sexual abuse (Simkin & Ancheta, 2005).
- Psychological stress and anxiety can be stimulated by many factors. Environmental stress can be caused by arriving on labour ward with its bright lights, unfamiliar noises and lack of quiet privacy, in addition the staff may be busy; a minority even unsupportive or uncaring. (For more information on preparing a good birth environment see Chapter 1.)
Analgesia
- Epidural anaesthesia offers total pain block but can cause reduced mobility, reduced circulating natural oxytocin with poor contractions, malrotation, delay in the first and second stage of labour with associated increased interventions (Dickersin, 2000). Epidural rates vary dramatically between units, suggesting that it is not women who always choose this form of analgesia but those who ‘care’ for them. If dystocia is to be prevented, alternative methods of pain relief should be explored first and epidural reserved for those women who genuinely request it.
- Opiates, e.g. pethidine can make the woman sedated, drowsy and immobile and can indirectly affect progress.
Conversely, natural methods of working with pain (see Chapter 1 for more information) include good one-to-one midwifery support, adopting comfortable positions, soaking in warm water, breathing, relaxation, massage and touch. These not only encourage pain-relieving endorphin release but are proved effective at facilitating labour progress.
- Deep warm water immersion may facilitate the birth process for some women through relaxation and pain-relieving qualities. One small study found that water immersion was as effective a treatment intervention in nulliparas with dystocia as standard augmentation and had fewer associated side effects (Cluett et al., 2004).
Prolonged latent phase
‘Some women, having no idea what to expect from early labour, ‘over-react’, that is they are preoccupied with every contraction and they may rush to use learned coping techniques that are more appropriate for active labour. They often expect to be 5 or 6 cm dilated when they are first checked and are crushed when they are examined and found to be only 1 to 2 cm … The caregiver must help to acknowledge the woman’s disappointment, giving her some suggestions to reduce the intensity of the contractions and proceed to calm and relax her. She will need help to get her head back to where her cervix is’ (Simkin & Ancheta, 2005).
The latent phase of labour sometimes lasts for several days (Burvill, 2002) and does not respond well to interventions such as ARM or oxytocics (Simkin & Ancheta, 2005). In the absence of problems, this stage requires no medical intervention other than effective explanations, reassurance and support. Good support from the midwife and a ‘wait and see’ course of action will do much to help a woman through a long latent phase.
Midwifery care
A prolonged latent phase can leave the woman exhausted and demoralised as well as doubting her body’s ability to continue to labour without problems. One study found that women admitted in the latent phase of labour experienced a need for handing over responsibility for the labour and the well-being of the unborn baby. Reasons identified were the following: longing to complete the pregnancy; having difficulty managing the uncertainty; having difficulty enduring the slow progress; suffering from pain to no avail; and oscillating between powerfulness and powerlessness. The researchers suggest midwives have a vital role in helping women cope by validating their experienced pain and confirming the normality of the slow process, as well as offering information and support (Carisson et al., 2007).
- Women will benefit from their midwife sitting quietly with them through several contractions, chatting, offering empathic acknowledgement of the woman’s pain, giving reassurance.
- Discuss practical ideas for coping with contractions such as:
- Soaking in a warm bath, massage, hot water bottle.
- Distractions and keeping busy such as going for a walk, cooking, watching a film.
- Soaking in a warm bath, massage, hot water bottle.
- If it is night time or the woman feels exhausted she should aim to rest and doze for periods (even if she cannot sleep), and keep cosy with a hot water bottle. Suggest side-lying, supported by cushions or a duvet (preferable to lying on her back).
- Before leaving the woman to labour, or discharging her home if in hospital, ensure that she knows how to get in contact with you if she needs to.
- For some women prolonged, persistent pain is hard to bear and a minority request some form of pharmacological analgesia or epidural. Although this has the potential to open the floodgates to medical intervention, it may be the appropriate choice for that woman in her situation. Pethidine may cause contractions to slow down, offering some respite as well as the potential for the woman to doze and relax.
- For more information on the latent phase of labour, see Chapter 1.
Prolonged active first stage
The active phase should see contractions increasing in frequency, strength and pain. It can be useful to ask ‘do the woman’s contractions seem the same or more frequent, and more painful, than an hour ago?’
It should be standard practice to share the decision-making process with the woman in labour. While some women with slow progress may feel exhausted and demoralised, and welcome assistance, others will be coping well, ‘gone into themselves’, oblivious to the passing of time.
Midwifery care
Try to identify the cause for slow progress; directly ask the woman if anything is worrying her. Sharing information, explanations and offering possible solutions for specific anxieties can help. Avoid offering ‘empty’ reassurances, ‘don’t worry about that, you’ll be fine’, as this will do little to address her anxieties and even unintentionally suggest that the matter has been discussed and is somehow resolved.
As a midwife you can control the environment: ensure lights dim, doors and curtains drawn, maintain privacy, keep interruptions to a minimum and encourage her partner offer massage, touch and support. It can be useful to also address physical causes: is she hungry or thirsty; when did she last pass urine; have you advised mobilising/upright postures?
In some cases such as a malposition, simple mobilisation and accepting that progress will be slower will help (see ‘Malpresentations and malpositions in labour’).
- Consider ARM (see Chapter 2)
- VE 2 hours after ARM to check progress (NICE, 2007)
‘When delay in the established first stage of labour is confirmed in nulliparous women, advice should be sought from an obstetrician and the use of oxytocin should be considered. The woman should be informed that the use of oxytocin following spontaneous or artificial rupture of the membranes will bring forward her time of birth but will not influence mode of birth or other outcomes.’
- Continuous labour support reduces labour duration and interventions (Hodnett et al., 2003).
- ‘Lay’ attendants are helpful: doulas, female relatives or friends can provide warmth, comfort and care (Simkin & Ancheta, 2005).
- If you are busy, call in additional staff, or suggest getting family/friends to act as additional birth supporters.
- Even if the woman is exhausted, upright positions are usually possible and more comfortable than semi-recumbent.
- Gravity-enhancing positions appear to shorten the second stage compared with supine/lithotomy positions which increase fetal heart anomalies, dystocia, epidural use, episiotomy and instrumental delivery (Gupta et al., 2000; RCM, 2005).
- Upright positions appear to help align pelvic bones and the shape/capacity of the pelvis, optimising a ‘good fit’ between baby and pelvis (Simkin & Ancheta, 2005). Squatting and kneeling significantly widen the pelvic outlet (Borrell & Fenstrom, 1957; Russell, 1982).
- Lying supine may cause the uterus to press on the spine, altering the angle of the uterus, resulting in poor alignment of the baby in the pelvis (Sutton & Scott, 1994).
(See also p. 14 for evidence of improved clinical outcomes with non-supine positions.)
- Massage, stroking, hand holding, and close contact in general increases endogenous oxytocin production, thereby stimulating contractions (Simkin & Ancheta, 2005).
- Give partners ‘permission’ to get in close and hold the woman; encourage attendants to offer comfort and massage and provide privacy for this.
- Touch is very personal; some women do not like it. Use this simple intervention with care.
- Acupressure remains unevaluated, however it is worth considering as it is simple, harm free and may do good. Simkin and Ancheta (2005) describe applying firm pressure for 10–60 seconds over the tibia (4 fingers width up from the inner ankle bone) or to the Ho-ku point of the back of the hand (where the metacarpal bones of the thumb and index finger meet). They suggest this may feel tender but is worth repeating several times if necessary.
- Stimulating the nipples causes natural oxytocin release which enhances contractions (Kavanagh et al., 2005).
- The woman can lightly stroke one or both nipples; most women will naturally require privacy for this.
- Some women may not want to try this intervention which they may find embarrassing, uncomfortable or irritating.
- An anxious woman may find a relaxing bath stimulates oxytocin and endorphin release (Ockenden, 2001).
- Water is as effective as standard augmentation in nulliparas with dystocia and reduces epidural use (Cluett et al., 2002).
- Long immersion can sometimes slow labour (Odent, 1998) but this is resolvable by leaving the pool.
- For women with slow progress, ARM did not affect further oxytocin use but did seem to have a protective, positive effect on subsequent labour progress and duration (Smyth et al., 2007).
- While multiparous women had no differences overall, nulliparas appeared more sensitive to ARM, and its use appeared to reduce second-stage duration and chances of low Apgar score (7 or less) at 5 min (Smyth et al., 2007).
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