Slow progress in the active phase of labour: partograph decision-making

Interpretation: this is not normal active-phase progress. From 4 cm to 5 cm in six hours is roughly 0.17 cm/hour, while the expected minimum in the active phase is about 1 cm/hour (with 0.5 cm/hour as the outer limit in many partographs). The partograph plots to the right of the alert line, which is a mandatory action trigger, not a document to complete retrospectively. The contractions are also inadequate: two in 10 minutes lasting 20-25 seconds will not efface and dilate a cervix, since effective labour needs roughly three to four contractions in 10 minutes lasting 40-60 seconds.

Possible explanations, and which I can act on:

• Hypotonic uterine dysfunction - the most likely explanation given the weak, infrequent contractions. This is treatable with amniotomy and titrated oxytocin once obstruction is excluded.
• Dehydration and ketosis - she has taken about 200 mL in eight hours and has vomited. This is correctable now and may itself be reducing contractility.
• Full bladder - no voiding for five hours. A distended bladder inhibits contractions and must be emptied.
• Occipito-posterior position - explains back pain and inefficient contractions; mobilising, upright positions and time may help rotation.
• Cephalopelvic disproportion - cannot be excluded yet. It can only be judged once contractions are adequate; the warning signs are moulding, caput succedaneum, a Bandl's ring, and lack of descent or cervical change despite good contractions.
• Exhaustion and fear - pain relief and reassurance may improve the pattern.

The safe sequence is to correct the reversible factors first, then reassess, then augment only if there is no obstruction.

Supportive measures first (roughly 1-2 hours):

• Encourage oral fluids or start an IV infusion if she cannot drink; treat ketosis with dextrose-containing fluid if indicated.
• Empty the bladder: encourage voiding, catheterise if she cannot.
• Upright and mobile positions, use of a birth ball, and kneeling or leaning forward for the occipito-posterior position.
• Continuous support and explanation; simple analgesia, and consider pethidine only with awareness that it can further slow an already inefficient labour and affects the newborn if delivery is near.
• Reassess contractions, pain, descent and the fetal heart after these measures.

Checks before oxytocin:

1. Confirm the indication and that the partograph documents it; obtain informed consent and explain the risks of hyperstimulation and fetal distress.
2. Reassure fetal status with a CTG before starting.
3. Exclude obstruction and contraindications: gross moulding or caput, high head not applied, suspected disproportion, malpresentation, placenta praevia, previous classical caesarean, or hypertonic uterus.
4. Perform amniotomy only if the head is well applied and the cord presentation has been excluded; note liquor colour.
5. Prescribe and prepare the infusion with an independent double-check of the drug, concentration, rate and pump.

Running it: start at a low rate (about 1-2 mU/min) and titrate at intervals of at least 30 minutes according to a written protocol, aiming for three to four contractions in 10 minutes, never leaving her unattended. Reassess cervical dilation in 2-4 hours. Stop the infusion for hyperstimulation, fetal heart abnormalities, suspected obstruction or a request from the woman, and document every change.

This is a deteriorating picture with two problems that must be managed simultaneously.

Problem 1 - hyperstimulation with late decelerations: late decelerations repeated after every contraction indicate impaired placental exchange, and the contraction pattern is now excessive. Stop the oxytocin immediately, turn her into the left lateral position, give an IV fluid bolus, administer oxygen, call the obstetrician and prepare for continuous monitoring. Do not restart oxytocin. If the pattern does not recover, she needs expedited delivery, likely by caesarean section.

Problem 2 - possible cephalopelvic disproportion: after two hours of adequate contractions she has made only 1 cm of progress, and there is now significant caput and moulding with the head still high and occipito-posterior. That combination suggests the head is not descending despite good contractions. Augmentation should not be pushed further; the moulding score and lack of descent are the warning signs, and continuing oxytocin would risk uterine rupture and worsening fetal hypoxia.

Actions: document the time oxytocin was stopped and every intervention; keep the woman and her family informed and obtain consent for transfer to theatre; prepare for a category-1 or category-2 caesarean depending on the fetal heart; arrange a paediatric team; continue monitoring until delivery; in the operating theatre, avoid ergometrine and be ready for postpartum haemorrhage because a long labour with an atonic uterus is a risk factor. After the event, complete an incident review of why the partograph was allowed to run so far to the right of the action line.