From the Guidelines
The management of a prolonged active stage of labor should prioritize identifying and addressing the underlying cause, ensuring maternal and fetal wellbeing, and considering cesarean delivery if there is compelling clinical evidence of cephalopelvic disproportion or if interventions fail to progress labor. The step-by-step management involves:
- Confirming the diagnosis by documenting adequate contractions and cervical dilation less than 1 cm per hour in nulliparous women or less than 1.5 cm per hour in multiparous women 1
- Assessing maternal position and encouraging upright positions or walking to optimize fetal descent
- Ensuring adequate hydration with IV fluids if needed, typically lactated Ringer's solution at 125 mL/hour
- Augmenting labor with oxytocin (Pitocin) starting at 1-2 mU/min, increasing by 1-2 mU/min every 30 minutes until adequate contractions are achieved (maximum 20-40 mU/min depending on institutional protocol) 1
- Offering epidural analgesia for pain management if requested, as it doesn't significantly slow labor progress when properly administered
- Continuously monitoring fetal heart rate and maternal vital signs
- Assessing for cephalopelvic disproportion by evaluating fetal position, station, and molding
- Considering amniotomy if membranes are intact and progress remains stalled despite adequate contractions for 4 hours
- Providing emotional support and clear communication about interventions throughout management Key factors to consider include:
- Cephalopelvic disproportion, which occurs at a rate of 25% to 30% in association with protracted active phase labor 1
- Inhibitory factors such as high dermatome level of motor or autonomic neuraxial blockade or excessive narcotic analgesia
- Fetal macrosomia, hydrocephalus, malposition, or malpresentation
- Uterine overdistention by multiple pregnancy or polyhydramnios
- Unexplained insufficient uterine contractility
- Maternal obesity, advanced age, and chorioamnionitis The underlying physiology involves the need for coordinated uterine contractions of sufficient strength and frequency to overcome soft tissue resistance and allow fetal descent. If all interventions fail and maternal exhaustion or fetal distress develops, cesarean delivery may be necessary, but this decision should be made after giving adequate time for interventions to work 1.
From the FDA Drug Label
Oxytocin Injection, USP (synthetic) is indicated for the initiation or improvement of uterine contractions, where this is desirable and considered suitable, in order to achieve early vaginal delivery for fetal or maternal reasons It is indicated for (1) induction of labor in patients with a medical indication for the initiation of labor, such as Rh problems, maternal diabetes, pre-eclampsia at or near term, when delivery is in the best interest of mother and fetus or when membranes are prematurely ruptured and delivery is indicated; (2) stimulation or reinforcement of labor, as in selected cases of uterine inertia;
The step-by-step management of a prolonged active stage of labor (protracted active phase of labor) may involve:
- Stimulation or reinforcement of labor using oxytocin, as indicated for selected cases of uterine inertia 2
- Monitoring of both the mother and the fetus to determine the best course of action
- Evaluation of the need for augmentation of labor with oxytocin, if uterine contractions are not sufficient to progress labor However, the exact steps may vary depending on the individual case and the clinical judgment of the healthcare provider.