Treatment
If slow progression of active first stage of labour is associated with lack of regular uterine contractions, the stimulation of uterine contractions with oxytocin and amniotomy is a reasonable clinical choice. There is lack of evidence on how the sequence of amniotomy and oxytocin infusion affects outcomes and this is a research priority.26 Augmentation of labour is the process of stimulating the uterus to increase the frequency, duration and intensity of contractions after the onset of spontaneous labour. It has commonly been used to treat delayed labour when uterine contractions are assessed to be insufficiently strong or inappropriately coordinated to dilate the cervix. Labour augmentation has traditionally been performed with the use of intravenous oxytocin infusion and/or artificial rupture of amniotic membranes (amniotomy).26 Augmentation with oxytocin alone should be performed when indicated as treatment of confirmed delay in progress of labour. For a multiparous woman with confirmed delay in the established first stage of labour, an obstetrician should perform a full assessment, including abdominal palpation and vaginal examination, before a decision is made about using oxytocin. If oxytocin is used, the time between increments of the dose is no more frequent than every 30 minutes until there are 4–5 contractions in 10 minutes. The start dose of oxytocin for augmentation, and the increments, should be the subject of further research.10
The decision to rupture the membranes should be made on the basis of other clinical considerations of the progress of labour, after explaining to the woman and her companion what the procedure involves and that it will shorten labour by about an hour and may increase the strength and pain of contractions. It is also mandatory to have special consideration if the woman has HIV or HBV, where amniotomy is best avoided to reduce risk of infection to the baby. Whether or not a woman has consented to an amniotomy, all women with suspected slow progression of active first stage should be advised to have a vaginal examination 2 hours later, and a diagnosis of delay is made if progress is less than 1 cm.10 If thick meconium is evident or fetal distress is suspected through abnormal fetal heart rate auscultation, it is necessary to have a medical review for a plan of care when there are multiple co-existent problems to decide the mode of birth. Management of uterine contraction abnormalities meconium stained amniotic fluid are addressed in other manuscripts in this series.27
Where obstructed labour or cephalopelvic disproportion is suspected, a medical review should be undertaken to consider delivery by C-section and preparations should be made for neonatal resuscitation.4