Prolonged Labor, Delayed C-Section, and Hypoxic-Ischemic Encephalopathy (HIE)
Medical professionals have established timelines for what is considered a “normal progression” of labor. If some of the markers for progress (such as cervical dilation and effacement) are delayed or stalled, staff must evaluate whether there is an “arrest of labor.” If there is, medical professionals may try a number of different interventions to assist with a vaginal birth. However, allowing a labor to continue for too long carries health risks for both the mother and child, including oxygen deprivation in the child, hemorrhaging, permanent injury, infection and trauma. Therefore, if initial attempts to intervene are unsuccessful, medical professionals must be prepared to move onto a C-section delivery in order to ensure that harm from prolonged labor is avoided.
What Is Prolonged Labor?
Labor is considered normal when uterine contractions result in progressive dilation and effacement of the cervix. Normal labor progresses slowly through the initial (latent) phase. When the cervix is dilated more than 4 cm, the more rapid, active phase of labor begins. During active labor, the cervix should progressively dilate at a rate of no less than 1.2 cm per hour (for first babies) or 1.5 cm per hour (for subsequent babies). If labor progresses more slowly than this, a woman may be experiencing an arrest of labor. Arrest of labor is an absence of progress – measured by cervical dilation and descent of the presenting part of the baby – for at least 2 hours.
There are competing studies defining prolonged first and second stages of labor. Some studies have found that labor is prolonged when the duration of the first and second stages of labor combined is greater than 20 hours for a first pregnancy, and greater than 14 hours for women who have previously given birth. Other experts say that prolonged labor occurs after 18-24 hours of the combined first and second stages. Prolonged labor is more common in a first pregnancy and in women over the age of 35 years.
Causes of Prolonged and Arrested Labor
Prolongation and arrest of labor are primarily caused by mechanical impediments and/or inadequate contractions, both of which are discussed in this section. Listed below are complications that can cause prolonged and arrested labor:
The normal position of the baby is longitudinal, with the baby’s spine parallel to the mother’s spine. The baby lies in a completely flexed position, with the chin touching the chest and the arms and legs flexed in front, and normally faces the mother’s back for a smooth delivery.
Any change in the normal position can cause abnormal labor. Malpresentations include the following:
- A breech presentation, in which the baby’s legs or buttocks present first
- A face presentation, in which the baby’s face is in position to exit the birth canal first
- A brow position, which is similar to face presentation, but the baby’s neck is less extended. A fetus in brow presentation has the chin untucked, and the neck is extended slightly backwards.
- An asynclitic presentation, in which the baby’s head is presenting first, but tilted toward one shoulder. This causes the head to no longer be in line with the birth canal.
Cephalopelvic Disproportion (CPD)
CPD occurs when the baby’s head is larger than the mother’s pelvic passage or birth canal (this is sometimes called “true CPD”), or the baby presents in a position that will not allow him or her to descend through the pelvis (see: “Fetal Malpresentations”). Causes of CPD include:
- The baby is abnormally large. This can be caused by gestational diabetes and other conditions that cause a baby to be macrosomic (weight is > 4000 or 4500 grams) or large for gestational age. Other conditions that may contribute to the baby’s head or body becoming too large during pregnancy include post-term pregnancies (post-maturity) and hydrocephalus (fluid in the baby’s brain that leads to swelling).
- Clinically small maternal pelvis
- Bony growths on the pelvis (pelvis exostoses)
- Malpresentation of the baby
- A bone in the spine slips out of position and onto the bone below it.
Problems with Uterine Contractions
Inadequate uterine activity is the most common cause of prolongation and/or arrest disorders in the first stage of labor, and it refers to uterine activity that is either not sufficiently strong or not appropriately coordinated to dilate the cervix and expel the baby.
The uterine muscle may fail to contract properly when it is grossly stretched, as in twin pregnancy and hydramnios (excess amniotic fluid). Presence of tumors in the uterine musculature can also affect uterine contraction.
Inadequate contractions may be treated with uterine stimulation. This is generally accomplished with Cytotec or Pitocin (synthetic oxytocin). Too much of these drugs can cause uterine hyperstimulation, which can lead to birth asphyxia and hypoxic-ischemic encephalopathy (HIE) in the newborn. When contractions are too fast and strong, the placenta often cannot recharge with an adequate supply of oxygen-rich blood for the baby. As hyperstimulation continues, the baby gets progressively more oxygen deprived. If the contractions are too close together (consistently more than 5 contractions every 10 minutes), the drugs should be stopped. Use of Cytotec or Pitocin requires very close monitoring of the baby’s heart rate; the baby must be quickly delivered at the first signs of distress.
Excessive use of painkillers or anesthesia can cause inefficient uterine action and may prevent voluntary effort by the mother to deliver the baby during the second stage of labor. Research shows that anesthesia can increase the length of the second stage of labor, and that it increases the use of both Pitocin and birth-assisting tools like forceps and vacuum extractors during delivery.
Cervical Dystocia or Stenosis
The term cervical dystocia is used when the cervix fails to dilate properly and remains at the same position for more than 2 hours after the latent phase of labor. The cervix may fail to dilate because it is fibrosed from previous operations, such as cone biopsy (type of cervical biopsy in which a cone-shaped piece of tissue is removed), or due to the presence of tumors.
Signs and Symptoms of Prolonged and Arrested Labor
- Labor extends for more than 14 – 20 hours, depending on whether it is a first birth.
- The mother looks exhausted and distressed; dehydration may be present, and the mouth may be dry due to prolonged mouth breathing.
- Pain may be more at the back and sides of the body, radiating to the thighs, rather than from the uterus in the abdomen. This is due to excessive and prolonged pressure on the muscles and ligaments of the back.
- Labor pains may initially be severe, frequent and prolonged, but later decrease and become very mild as the muscles become fatigued.
- Pulse rate is often high due to dehydration, exhaustion, and stress.
- The large intestines are dilated and can be felt along both sides of the uterus as large, thick structures filled with air.
- The uterus is tender upon touch and does not relax fully between contractions.
- Fetal distress may develop.
- Membranes may or may not rupture early. In early rupture, there is a risk of infection of the baby if proper antibiotics are not prescribed.
Dangers of Prolonged and Arrested Labor
Dangers to the Fetus:
- Fetal distress due to decreased oxygen reaching the baby.
- Intracranial hemorrhage or bleeding inside the baby’s head.
- Increased chances of operative delivery, such as C-sections and use of forceps or vacuum extractors.
- Long-term risks of the baby developing permanent injuries, such as cerebral palsy and hypoxic-ischemic encephalopathy (HIE).
Dangers to the Mother:
- Intrauterine infections
- Trauma and injuries in the maternal birth passage (eg: cervical tears, vaginal wall tears).
- Postpartum hemorrhage.
- Postpartum infection.
Diagnosing Prolonged and Arrested Labor | Preventing Hypoxic-Ischemic Encephalopathy (HIE)
In diagnosing prolonged and arrested labor, the medical team will likely examine the following:
- Whether signs and symptoms of the condition are present
- The duration of labor
- The frequency and strength of contractions
- Whether labor is abnormal according to Friedman’s three stages of labor. A normal course of labor consists of the following stages:
- Stage 1 of labor: There are uterine contractions leading to complete cervical dilation. This stage is divided into the latent and active phases. In the latent phase, irregular uterine contractions occur with slow and gradual cervical effacement and dilation. The active phase is demonstrated by an increased rate of cervical dilation and descent of the baby. The active phase usually starts at 3-4 cm of cervical dilation, and is subdivided into the acceleration, maximum slope, and deceleration phases.
- Stage 2 of labor: This is defined as complete dilation of the cervix to the delivery of the infant.
- Stage 3 of labor: Stage 3 involves delivery of the placenta.
Treating Prolonged and Arrested Labor to Prevent Birth Injuries and Hypoxic-Ischemic Encephalopathy (HIE)
If a woman has a prolonged active phase of labor, physicians sometimes administer Pitocin/oxytocin and wait to see if it is effective. If the oxytocin does not work and arrest of labor has ensued, a C-section delivery is usually performed.
Physicians may use Pitocin/oxytocin with the intent to avoid the need for C-section delivery. However, research shows that Pitocin administered during the first stage of labor does not decrease the chances of a C-section delivery or delivery using forceps.
On the other hand, high dose oxytocin regimens (compared to low dose regimens) have been found to decrease the rate of C-sections and duration of labor, but were also associated with hyperstimulation of the uterus, or tachysystole, which is a condition of excessive uterine contractions. This can be damaging to the baby in several ways, including a decrease in supply of blood and oxygen to the baby, which can cause birth asphyxia and hypoxic-ischemic encephalopathy (HIE).
Pitocin/oxytocin must be used with caution because at any dose, there is a risk of tachysystole, although the risk and degree of tachysystole is lower at lower doses.
Pitocin/oxytocin may not be used when the following conditions are present:
- The mother is in the first stage of labor.
- The mother is in the second stage of labor before crowning of the baby’s head.
- There is loss of tone in the uterine musculature (uterine atony).
- The mother has preeclampsia, eclampsia, or sepsis.
- There is significant CPD.
- The baby is in an unfavorable position, such as shoulder or face presentation.
- The baby is in distress and delivery is not imminent.
- Vaginal delivery is contraindicated, as in cases of active herpes genitalis, total placenta previa, vasa previa, or a prolapsed umbilical cord.
- Adequate uterine activity fails to achieve satisfactory progress.
Artificial Rupture of Membranes
Artificial rupture of the membranes, or an amniotomy, is a procedure whereby the physician ruptures the woman’s membranes with a finger or special tool in order to accelerate labor. An amniotomy may only be performed if the following criteria are met:
- The mother should be in active labor (cervical dilation of 4 or more cm).
- The mother should be at term.
- The head should be engaged (at 0 station or more).
Risks of amniotomy include the following:
- There is an increased risk of umbilical cord prolapse.
- There is an increased risk of infection if there is prolonged time between rupture and birth. Infection can cause the baby to have sepsis, meningitis, hypoxic-ischemic encephalopathy (HIE), and cerebral palsy.
- The baby may turn to a breech position.
Sometimes, elective amniotomy is performed in women with normal labor progression. However, this is recommended against by both The Cochrane Collaboration and the American College of Obstetricians and Gynecologists (ACOG). A 2013 Cochrane review found no evidence that amniotomy could shorten the first stage of labor. They did, however, observe a possible increase in the need for C-sections. Based in part on that Cochrane review, the American Congress of Obstetricians and Gynecologists (ACOG) also released a statement on routine amniotomy, saying that “for women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.”
Forceps and Vacuum Extractors
These are instruments that are used to assist vaginal deliveries. If used properly, they can speed up delivery of the baby. If used improperly, they can cause traumatic birth injuries to the baby, which can be permanent. Injuries associated with improper use of these instruments include the following: brain bleeds and hemorrhages, seizures, Erb’s palsy, hypoxic-ischemic encephalopathy, and cerebral palsy.
A C-section is performed when a vaginal delivery would put the baby or mother’s life or health at risk. Some conditions that require the baby to be delivered immediately include fetal distress, uterine rupture, and cord prolapse. Sometimes physicians fail to perform an emergency C-section when one is indicated, or they wait too long to perform one. Other times, the C-section may be ordered, but the physician lacks skill in the procedure, or the hospital is ill-equipped for it. Delay in performing a C-section can lead to permanent injuries in the baby, such as cerebral palsy and hypoxic-ischemic encephalopathy (HIE).
If a woman is at risk of having any type of abnormal labor, intensive clinical monitoring should be done. This includes recording the pulse, blood pressure, and fetal heart sound (FHS) every hour, and dilation of the cervix every two hours. Fetal heart rate strips should be checked even more frequently. If, in spite of the above procedures, labor fails to accelerate, or if fetal distress develops, an emergency C-section should be performed.
It is essential for the medical team to monitor the mother and baby very closely during labor and delivery, especially if there are indicators that the labor is or will be prolonged or arrested. The medical team must be prepared to handle complications and to promptly perform a C-section delivery if necessary. It is negligence when a mother and baby are not properly assessed and monitored. Failure to act skillfully and quickly also constitutes negligence. If this negligence leads to injury of the mother or baby, it is medical malpractice.
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Related Articles and Blogs
- Pitocin and Birth Injury
- Blog: Rewriting the Rules for “Normal Labor”
- Improper Fetal Monitoring
- Hypoxic-Ischemic Encephalopathy (HIE)
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- Zhang J, Landy HJ, Branch DW, et al. Contemporary patterns of spontaneous labor with normal neonatal outcomes. Obstet Gynecol 2010; 116:1281.
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