Failure to progress in the second stage of labour.

Spontaneous vaginal delivery without obstetric intervention remains the goal for most pregnant women. Midwives and obstetricians aim to support women in achieving this result, which is associated with the lowest risk of morbidity for both mother and baby. Despite the best efforts of the labouring woman and her carers, some women will fail to progress in the second stage of labour, and obstetric intervention will be required. This review evaluates recent data addressing the diagnosis, aetiology and management of failure to progress in the second stage of labour, and explores aspects of maternal and neonatal morbidity associated with this event.     

Management of poor progress in labour

Nulliparous patients experience poor progress in labour far more commonly than multiparous, with “failure to progress” or “dystocia in labour” becoming one of the leading indications for caesarean section in nulliparous populations. A wide range of practices exist which aim to avoid prolonged labour. This paper aims to discuss the management of poor progress in labour focusing on the nulliparous population at term with a cephalic presentation, Robson Groups I and IIA. We will then proceed to illustrate cases of poor progress and their management in the National Maternity Hospital (NMH) Dublin, Ireland. It should be noted that all references to multiparous populations in this paper refer to those at term, with a cephalic presentation and without a previous uterine scar- Robson Groups III and IVa. This article focuses on the ‘active management of labour’ (AML), pioneered in Dublin, and uses examples to contrast this with management of labour according to NICE guidance.     

Segmental epidural analgesia in labour: related to the progress of labour, fetal malposition and instrumental delivery.

The effect of low-dose continuous segmental epidural analgesia given during the first stage of labour on the progress of labour, the frequency of fetal malpositions and the rate of vacuum extractions was studied prospectively in 100 parturients (epidural group). The results were compared with 100 parturients given none or conventional analgesia (control group). The results showed that in the primiparous epidural group the progress of labour before analgesia was induced was significantly slower than in the control group. After the block, however, the subsequent course of the labour was of equal duration in both groups. The durations of the second stages of labour did not differ significantly between the groups. The differences in fetal malpositions at delivery were statistically insignificant. Nor did the rate of vacuum extractions, 8% in the primiparous and 0% in the multiparous epidural group, differ statistically from the corresponding rate in the control groups. The results signify a normal progress and outcome of labour after low-dose segmental epidural analgesia.     

The management of preterm labour

Preterm labour is a major cause of perinatal mortality and morbidity. The aetiology is multifactorial and attempts to predict preterm labour are unsuccessful. At the present time prophylaxis is unhelpful and the obstetrician must manage preterm labour as it arises. The management of preterm labour remains controversial because of the difficulty in conducting good clinical trials. Antepartum glucocorticoids are effective in reducing the incidence and severity of respiratory distress syndrome. The effect is dependent upon a number of factors such as race, fetal sex, gestational age, state of the membranes, fetal asphyxia and timing of delivery in relation to therapy. Tocolytics are effective in stopping contractions but this does not produce a significant prolongation of pregnancy or reduce perinatal mortality or morbidity. It is because they can suppress contractions and delay delivery for a short time that great care should be taken that this short delay is used beneficially, e.g. in-utero transfer, or steroid therapy. It is also important that this suppression does not result in an inappropriate delay where early delivery is indicated because of infection or fetal distress. Steroids, tocolytics and antibiotics are potentially hazardous although all may benefit the fetus. The particular risks versus benefits of each form of therapy should be carefully considered for the particular presentation of each individual patient. While all these agents given antenatally are of potential benefit to the fetus and neonate, prolongation of pregnancy for its own sake or for the sake of allowing time to administer such agents is no substitute for delivery of an infant in optimum condition.     

The management of preterm labour

This article explores the complexities of diagnosing and managing preterm labour and highlights the importance of tailoring labour and delivery care to the individual, based on gestation and neonatal prognosis. Available diagnostic criteria and interventions to optimize the preterm infant are discussed, and the limitations of evidence to inform current practice described. The benefit of national improvement drives in the quality and consistency of preterm labour care is introduced to encourage local education and clinical training to combat the harmful sequelae of preterm birth.     

Problems and challenges in the management of preterm labour

The main problem with preterm labour is our lack of progress in the successful management of this condition. We need to reassess our approach to this problem because preterm labour is not a disease, but an event, which may result from multiple independent pathways. This problem has also been affected significantly by medical advances such as infertility treatments and changes in neonatal survival at the limit of viability. The specific challenges that we face in managing preterm labour include: problems with definition; aetiology, including genetic and infection components; diagnostic problems, such as true versus false labour and role of cervical length and fetal fibronectin; and specific interventions according to the antepartum, intrapartum and postpartum challenges. In order to address the main issue, and make future progress in the management of preterm labour, we should consider the implementation of a 'Postpartum Preterm Labour Diagnostic Workup Protocol'. These data/workup results could be entered on web-based databases for each preterm labour 'event'. An international research team could analyse data relating to specific aetiological patterns and subgroup analyses, leading to the collaborative development of 'aetiology specific' management modalities. This approach requires a close collaboration between clinicians and researchers, in order to make significant progress in this difficult area, and ultimately improve perinatal outcomes.     

Recent advances in the therapeutic management of preterm labour

Preterm labour and delivery pose an increasing problem to the obstetrician. Improvements in tocolysis with the recent introduction of new therapeutic targeting strategies, and a reappraisal of the safety and relative efficacy of some older compounds, have led to a tendency away from prescribing beta-sympathomimetic agents. Infection prophylaxis and promotion of fetal lung maturity are deemed advantageous, but treatment protocols have not been clarified. This review examines the important publications of the past year in these areas.     

The obstetric management of preterm labour

Preterm delivery remains the major cause of perinatal morbidity and mortality. It usually results from preterm labour, which may, in itself, have many causes.A detailed initial assessment (preferably using a standard protocol) should be undertaken in an attempt to diagnose any underlying pathology and to predict the likelihood of delivery. An appropriate plan of management can then be made, in conjunction with a senior experienced obstetrician and with the patient's informed agreement.Options are expediting delivery, delaying delivery or observation, the last two being combined with fetal therapy. Drug therapy can delay delivery in the short-term and should also be considered with ruptured membranes. Time gained allows for fetal therapy to have benefit and if necessary in utero transfer to a unit better equipped for neonatal intensive care. Fetal therapy with maternal administration of corticosteroids should be practised in almost all cases where there is a risk of respiratory distress syndrome. Thyrotropin releasing hormone therapy may soon be introduced.There are no data to support a number of practices such as prophylactic antibiotics with ruptured membranes and routine operative delivery even for the breech presentation.Most of the credit for improvements in neonatal morbidity and mortality must rest with the paediatricians. However, the obstetrician and midwife have a major role in presenting a neonate — who is not bruised or asphyxiated, is ‘matured’ and at an advanced gestation as possible — to paediatricians prepared to provide appropriate care.     

Mechanism and management of normal labour

The purpose of antenatal and intrapartum care is to ensure the birth of a healthy baby to a healthy mother. This should ideally be achieved with the minimum of interference compatible with a safe outcome. Complications may arise during the birth process, and it is important to be able to identify and address these at an early stage to prevent the serious sequelae that are still an unfortunate feature of modern Obstetrics. To identify deviation from the normal, it is important to have an appreciation of what constitutes normal pregnancy and labour. This article will first discuss the physiological mechanisms of the initiation of labour before turning to the mechanisms and management of normal labour.     

Time to rectify past mistakes and take a woman-centred approach to labour progress

In this article, the authors discuss a woman-centred approach to labour progress using an awareness of the physiological variations which exist in labour and they highlight the current WHO recommendations for labour progress. There is a call to action to protect the emotional and psychological well-being of women. This can be done through informed consent and valuing HOW we communicate with women as being equally important as WHAT happens during the birth process. Therefore, midwives and obstetricians should encompass an awareness of respectful communication in intrapartum care and be mindful of the language used. Supporting choice and control and empowering autonomy in women needs to be prioritized. Thus, maternity needs to take ownership and responsibility for the effects of past mistakes and move towards woman-centred care.     

Mechanisms and management of normal labour

It is essential that those proving antenatal and intrapartum care understand what constitutes normal labour. This allows complications that can arise at any stage to be recognized early and can help prevent serious sequelae. This review covers the physiology, mechanisms and evidence based management of normal labour.     

Mechanism and management of normal labour

It is important for providers of antenatal and intrapartum care to have an understanding of what constitutes normal labour. Complications may arise at any stage during labour, and early recognition and management may prevent serious sequelae. This review focuses on the physiology, mechanism and management of normal labour.     

Failure to prevent preterm labour and delivery in twin pregnancy using prophylactic oral salbutamol

A double blind, controlled study was performed to see whether the use of prophylactic oral salbutamol would reduce the incidence of preterm labour in twin pregnancy. Of the 144 women studied, 74 took salbutamol and 70 placebo. No difference was found in the length of gestation, birthweight or fetal outcome, although fewer babies suffered from respiratory distress syndrome in the salbutamol group. Women did not experience troublesome side-effects from salbutamol.     

Mechanisms and management of normal labour

Normal labour is a complex process involving hormonal, biochemical and mechanical interdependence. There are four phases of parturition: quiescence, activation, stimulation and involution. These reflect the transition from the maintenance of myometrial acontractility and cervical structural integrity, to progressive uterine contractions, cervical effacement and dilatation, delivery of the fetus and placenta, and recovery to the non-pregnant state. Whilst parturition is chiefly controlled by the oestrogen:progesterone ratio, multiple hormones such as prostaglandins, corticotropin-releasing hormone, oxytocin and relaxin play a role in the initiation, maintenance and progression of normal labour. The mechanical challenge of labour is overcome when progressive, effective contractions occur in conjunction with satisfactory fetal and maternal pelvic dimensions. Clinically, there are three stages in the management of normal labour, reflecting cervical dilatation up to 4 cm, delivery of the fetus, and the placenta, respectively. Robust knowledge of the mechanisms and management of normal labour is key to our understanding of when to clinically intervene and recognize areas where maternal and fetal morbidity can be reduced.