Management of Labor

Management of Labor
Algorithm Annotations Third Edition/May 2009
73. Management of Protracted Labor
If the patient in Stage II labor is not making progress, management of protraction disorders will include:
• Evaluation of maternal and fetal position. Consider having the patient move into different positions.
• Oxytocin augmentation.
• Allowing fetus to "labor down." Do not start active pushing as soon as patient is fully dilated.
Allow contractions to move the baby down (Fraser, 2000a [A]).
• Decreasing or stopping epidural anesthesia. Epidural anesthesia is associated with a prolongation
of the second stage of labor and an increase in oxytocin use and assisted vaginal delivery (Shields,
2007 [R]).
• Evaluation of fluid balance may be beneficial for affecting labor progress (American College of
Obstetricians and Gynecologists, The, 2003 [R]).
• Consideration of assisted delivery.
• OB/surgical consult if necessary.
(Minnesota Clinical Comparison and Assessment Project, 1991 [R]; Saunders, 1992 [B])
74. Is the Head Descending?
Prolongation of the second stage of labor beyond an arbitrary time limit is no longer an indication for assisted
vaginal or Caesarean delivery. As long as progress is being made and fetal monitoring is reassuring, the
patient can continue pushing (Cheng, 2004 [A]; Myles, 2003 [B]).
75. Assisted Vaginal Delivery Indicated?
If there is no descent for two hours despite optimizing labor, an assisted delivery or surgical consult is
suggested. Vacuum extraction or mid/low forceps delivery contraindications include:
• vertex is too high,
• provider is inexperienced,
• fetal distress with inability to do timely operative vaginal delivery, and
• patient refusal.
Note: When using vacuum extraction or forcep application with a suspected macrosomic infant, be aware
of the risk of shoulder dystocia.
(O'Driscoll, 1984 [C]; Rouse, 2001 [D]; Shields, 2007 [R])
Intrapartum Fetal Heart Rate (FHR) Monitoring Algorithm
Annotations
78. Continuous EFM-ext or EFM-int (if needed)
Electronic fetal monitoring (EFM) is indicated in all high-risk situations and in low-risk situations when the
auscultatory pattern is unclear or when 1:1 nursing staff is not available. Internal EFM may allow easier
patient positioning and promote patient activity by being less confining than external EFM. Low-risk patients
should be encouraged to be as active and mobile as possible.
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