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