When Ria Fu’s first contractions began on the evening of Dec 10, 2023, she braced herself for a long journey ahead. But she never imagined that labour would stretch beyond two days.

Without pain relief for most of the gruelling process, the 29-year-old first-time mother endured wave after wave of contractions. While the physical strain of her prolonged labour was immense, the emotional toll felt greater.

“The contractions were painful but beyond the pain, it was not knowing when it would end. After more than two days, it felt like there was no end in sight,” she said. “It affects your mental stamina … and I kept losing hope.”

Prolonged labour affects about one in 12 women – around eight per cent of those in labour, according to Dr Serene Thain, consultant at the Department of Maternal Fetal Medicine at KK Women’s and Children’s Hospital (KKH).

For some, labour is more than just a test of endurance. When it does not progress as expected, it can pose serious risks to both mother and baby.

WHEN LABOUR GOES ON FOR TOO LONG

Prolonged labour refers to labour that lasts longer than the typical duration for each stage of childbirth, said Associate Professor Su Lin Lin, senior consultant and head of Division of Maternal Fetal Medicine at Department of Obstetrics and Gynaecology, National University Hospital (NUH).

During the active first stage, when the cervix dilates from more than 3cm to 10cm (full dilation), labour generally progresses at a rate of at least 1cm per hour. During the second stage, when the cervix is at full dilation of 10cm to the delivery of the baby, the duration is generally less than three hours, said Assoc Prof Su.

It should be highlighted that before the active stages of labour, women go through the early (latent) phase as the cervix prepares for labour. They may experience abdominal cramps, mild backache and pass the mucus plug. This stage can last anywhere between hours to sometimes days, explained Dr Thain.

WHAT CAUSES PROLONGED LABOUR?

Labour can stall at any point due to various factors, said Dr Harvard Lin, consultant obstetrician, gynaecologist and urogynaecologist at the Asian Obstetrics and Gynaecology Centre.

For example, infrequent or weak contractions, or the shape of the mother’s pelvic bones may obstruct the passage of the baby’s head.

A large baby or baby who is not in the optimal position for vaginal delivery can also cause prolonged labour, added Assoc Prof Su.

Women of older maternal age, those with a high body mass index (BMI) or poorly controlled diabetes during pregnancy also face risks of prolonged labour.

RISKS TO MOTHER AND BABY

When labour fails to progress, mother and baby are at risk. They both face an increased risk of infection if the water bag has broken for a significant period of the time, said Assoc Prof Su.

Maternal exhaustion also becomes a concern, increasing the need for assisted delivery using vacuum or forceps, or a caesarean delivery.

Dr Thain noted that prolonged labour accounts for nearly a third of caesarean births.

Other risks that mothers face include postnatal haemorrhage due to uterine atony, a condition that occurs when the womb fails to contract effectively after delivery and can lead to excessive bleeding, she said. In rare cases, mothers may experience a tear in the womb, known as uterine rupture.

Prolonged labour can cause foetal distress due to reduced oxygen supply during long contractions, said Dr Lin.

Another complication called shoulder dystocia can also occur when the baby’s head is delivered, but one or both shoulders become stuck behind the mother’s pubic bone, impeding the birth of the rest of the body, added Dr Thain.  

Prolonged time in the birth canal can deprive the baby of oxygen, while positioning may increase the risk of nerve injuries or fractures, according to the Royal College of Obstetricians and Gynaecologists. Shoulder dystocia can also result in more severe vaginal tears.

EMOTIONAL IMPACT OF PROLONGED LABOUR

Prolonged labour can leave a deep emotional impact on some women. Dr Lin said that longer and more difficult labour leads to greater physical and emotional strain, making women more likely to feel overwhelmed and experience more pain.

“It can lead to feelings of disappointment or trauma, particularly for first-time mothers. This experience may even influence their attitudes or plans for future pregnancies,” he said.

For instance, women who go through prolonged labour may opt for a planned caesarean delivery in subsequent pregnancies while others develop a fear of childbirth or increased anxiety during subsequent pregnancies, Dr Lin added.

For 32-year-old Sarah, who requested not to state her full name, the emotional toll of prolonged labour is something she still remembers vividly three years on. She spent nine hours being “stuck” at 5cm dilation. A call was made for her to undergo a caesarean section.

What overwhelmed Sarah the most was the moment she had to sign the consent form for a caesarean section, deviating from her original plan of a vaginal birth.

Seeing her disappointment and sadness over the turn of events, her doctor Assoc Prof Su offered words of encouragement and support. “She reminded me that what was most important was that my baby is delivered safely,” Sarah told CNA Women. 

WHAT HAPPENS NEXT WHEN LABOUR STALLS?

Throughout labour, the mother’s symptoms and vital signs, such as blood pressure, pulse rate and temperature, are monitored closely. Vaginal examinations are performed at intervals by a healthcare professional, and the frequency depends on the stage and progress of labour, explained Dr Thain.

The frequency and duration of contractions, as well as the baby’s heart rate are monitored using a device placed on the mother’s abdomen.

According to the experts, some standard interventions for prolonged labour in the first stage include the artificial rupture of membranes (a procedure called amniotomy), which involves the practitioner manually puncturing the amniotic sac. An oxytocin drip may also be administered to stimulate or strengthen the contractions.

In cases where labour remains prolonged during the second stage, an assisted delivery using a vacuum or forceps may be necessary. “It is important to note that these interventions will be offered only if they are medically necessary, with the aim of increasing the chance of a vaginal delivery,” said Assoc Prof Su.

However, if there is evidence of foetal distress, meaning the baby’s heartbeat is abnormal, or if labour is not progressing despite regular strong contractions and medical interventions, a caesarean section may be recommended instead of continuing natural labour, she added.

What if the mother insists on continuing with vaginal delivery, despite labour going on for an extended period?

In such situations, doctors will continue to closely monitor the health of the mother and baby, said Dr Thain. The doctors will also discuss with the patient the risks of continuing the vaginal delivery compared to that of a caesarean delivery or instrumental delivery, ensuring that the mother fully understands the risks and benefits of all the options.

“Providing emotional support and addressing concerns that the mother may have is also essential, so that an agreed plan can be negotiated. Ultimately, doctors will respect the patient’s autonomy and decision whether to proceed with a trial of labour or a caesarean delivery,” said Dr Thain.

PREVENTING COMPLICATIONS

Prevention should begin early in pregnancy. Dr Lin advised expectant mothers with risk factors to discuss how to reduce the risk of prolonged labour with their doctors. While some risk factors, such as maternal age, cannot be changed, others can be managed.

“For example, women can speak to their healthcare provider about gaining weight and maintaining a healthy weight throughout pregnancy. That’s one way to lower the risk of prolonged labour since high BMI is a known risk factor,” he said.

For women whose risk factors cannot be modified, Dr Lin advised including the possibility of prolonged labour in their birth plan, and how to manage the situation, if it arises.

Assoc Prof Su encouraged expectant mothers to learn more about the labour process. This helps them feel more prepared during labour and understand when interventions might be necessary to minimise complications arising from prolonged labour.

“It is also important to have an open mind,” she said. “Each labour experience is unique and memorable, so it’s good not to have a fixed preconceived idea (of how labour should look like).”

Sarah and Ria believe that trusting their medical care team helped them navigate the challenges of prolonged labour and safely deliver their babies.

For Sarah, labour finally picked up as preparations for the caesarean section were underway, allowing her to have a vaginal delivery.  

“There was a great sense of relief, joy and of course, exhaustion when my baby finally arrived,” she recalled. “Even with an epidural, prolonged labour still tests your mental and emotional resolve. Extend grace to yourself if you feel emotional or exhausted.”   

Besides practical strategies like sitting on a birthing ball, Ria found that a resilient mindset makes a big difference.

“I kept reminding myself that every mum goes through this, that it wasn’t just me, and that it would end at some point,” she said.