From the Guidelines
Management of a prolonged active first stage of labor requires a systematic approach, starting with confirmation of the diagnosis by documenting cervical dilation less than 1.2 cm/hour in nulliparous women or less than 1.5 cm/hour in multiparous women during the active phase, as per the guidelines outlined in the American Journal of Obstetrics and Gynecology 1. The diagnosis of protracted active phase cannot be made if the gravida is still in the latent phase of labor, and identifying the onset of the active phase is crucial, as stated in the study published in the American Journal of Obstetrics and Gynecology 1.
Step-by-Step Management
- Confirm the diagnosis by documenting cervical dilation less than 1.2 cm/hour in nulliparous women or less than 1.5 cm/hour in multiparous women during the active phase, typically starting at 6 cm dilation, as recommended by the American Journal of Obstetrics and Gynecology 1.
- Assess the three Ps: Powers (contractions), Passenger (fetus), and Passage (pelvis), to identify any underlying causes of the prolonged labor, as suggested in the study published in the American Journal of Obstetrics and Gynecology 1.
- For inadequate contractions, start oxytocin augmentation using a low-dose protocol beginning at 1-2 mU/min and increasing by 1-2 mU/min every 30 minutes until adequate contractions (3-5 contractions in 10 minutes) are achieved, not exceeding 40 mU/min, as recommended by the American Journal of Obstetrics and Gynecology 1.
- Ensure adequate hydration with IV fluids (typically lactated Ringer's at 125 mL/hour) and consider amniotomy if membranes are intact, which can shorten labor by 1-2 hours, as stated in the study published in the American Journal of Obstetrics and Gynecology 1.
- Position changes should be encouraged, including walking, squatting, or using a birthing ball, to utilize gravity and pelvic dimensions to facilitate fetal descent, as suggested in the study published in the American Journal of Obstetrics and Gynecology 1.
- For pain management, offer epidural analgesia if desired, using low-concentration solutions (bupivacaine 0.0625-0.125% with fentanyl 2 mcg/mL) to minimize motor blockade, as recommended by the American Journal of Obstetrics and Gynecology 1.
Continuous Monitoring
- Throughout management, continuous electronic fetal monitoring is essential to detect any signs of fetal compromise, as stated in the study published in the American Journal of Obstetrics and Gynecology 1.
- If no progress occurs after 4 hours of adequate contractions with oxytocin, reassess for cephalopelvic disproportion or malposition and consider cesarean delivery, as recommended by the American Journal of Obstetrics and Gynecology 1. This approach prioritizes maternal and fetal wellbeing, while also considering the potential underlying causes of the prolonged labor, as outlined in the American Journal of Obstetrics and Gynecology 1.