Introduction
Spontaneous labour has been divided into phases and stages to facilitate clinical management. However, its actual progression has not yet been standardized for all women. The applicability of time limits in practice has been challenged by variations in definitions of the onset, phases and stages of labour.1 Active first stage starts at 5 cm of cervical dilatation, and for women with spontaneous labour onset, it usually does not extend beyond 12 hours in first labours, and 10 hours in subsequent labours.2-3 The second stage of labour duration has been proposed to last up to 2 hours in nulliparous (up to 3 hours if they had regional anaesthesia) and up to 1 hour or 2 hours in parous women without or with regional anaesthesia, respectively.4-5
It is difficult to determine the incidence of prolonged labour, because the accepted thresholds of normal and protracted labour6 and the diagnostic criteria for dystocia are not yet universally standardized and WHO is intensively working on achieving this. Therefore, prolonged labour reported widely ranges from 1.3% to 37% of all deliveries.7-8-9
Prolonged first stage of labour may be due to poor uterine activity, fetal size, abnormal fetal position or presentation, pelvic abnormalities resulting in cephalo-pelvic disproportion (CPD), or psychological reasons.10 Second stage may get unduly prolonged because of CPD, abnormal fetal position, and poor expulsive efforts resulting from conduction analgesia, sedation or maternal exhaustion.11 The consequences of a prolonged first stage and second stage could be postpartum haemorrhage, low 5-minute Apgar score or admission to the neonatal intensive care unit.11
Identifying slow progress that justifies interventions to accelerate labour is often challenging in clinical practice. This may have contributed to increasing interventions during labour and childbirth particularly the increased use of oxytocin augmentation and caesarean section for “failure to progress in labour”,12-13and associated maternal and newborn morbidities.14-15-16 Diagnosis and management of prolonged second stage of labour and its complications often poses a dilemma to the health provider regarding timing and type of intervention. 11 This is the stage in labour where the contribution of a skilled birth attendant is the most critical in ensuring a safe outcome.17
The following algorithms aim to guide health care providers in the management of spontaneous labour in women at low risk of perinatal complications and to summarize the clinical pathways for identifying, diagnosing, managing, and monitoring deviations from normal observations of labour and its progress.