Couple loses baby to prolonged labour

It can be avoided, says Dr Sikolia Wanyonyi, an obstetrician-gynecologist at the Aga-Khan University Hospital

The birth of a child brings with it unspeakable joy and that is why every expectant couple looks forward to this day. But what happens when prolonged labour dashes this joy and instead casts a cloud of anxiety?

Michael Ochieng’ Omondi, 31 and Veronica Akinyi Ochieng’, 25, found themselves face to face with prolonged labour on 21 April last year. Unfortunately, the young couple lost their new born son, barely 15 minutes after what turned out to be a painful experience for both of them, something they regret now that they know that the situation could have been averted.

On her due date, Akinyi and Ochieng’ say they were very enthusiastic ‘I was very eager and I had moved around and about Nairobi’s baby shops doing last-minute shopping,’ says Ochieng. ‘I was back home to await the turn of events but nothing happened. Then came the following day – a Saturday and my anxiety went beyond me. I would inquire about how she felt almost every minute as the clock ticked,’ Ochieng’ re-lives his anxiety

Sunday was God-sent as Akinyi started experiencing what she felt were labour pains, early in the morning. She was rushed to the neaest maternity hospital, next to their Zimmerman Estate home along Thika Road in Nairobi. ‘I was admitted on arrival at about 9 o’clock. I was examined and the medical personnel concluded that I was okay and going through normal labour,’ she says.

The clock ticked past as she lay in bed and being examined at hourly intervals. The labour was progressing very slowly with the pains now being felt in slow motion. She recalls being examined again at four o’clock just an hour before the working day was over.

Ochieng’, his patience waning, had now camped at his wife’s bedside as he enquired about the long wait. The nurses explained to me that it was taking long for her birth-canal to open. By the hour the day-time medical personnel checked out and handed over to those in the night-shift, she had dilated 8 centimeters and they told me they were waiting for her to get to 10 centimeters.’

Night fell and now he had to wait at the corridor outside the maternity ward. Hours ticked past and nothing was forthcoming. Tired and dejected, Ochieng’ left for home at about 10 o’clock after the medical personnel had assured him of some good news ‘They told me that she might be through by midnight. So I went home expecting that call at around midnight. But it never came. Instead I am the one who called at 1:00 a m., only to learn that she was still struggling.’

Early the following morning, Ochieng’, now devastated, made his way to the hospital to check on his wife. ‘I enquired if we were still safe and l was again told that the opening was taking too long and there was no need to refer.’

’A doctor friend of his who is a general practitioner happened to visit the couple at the hospital. Ochieng’ narrates: ‘He told me that my wife could be induced. But I was informed chat they could not dare to do so since there was no theatre facility at the hospital, something that we had overlooked when we did the booking. I also understood that being a religious mission-run hospital, the medical personnel could not interfere with the natural birth process on religious grounds.’

Eventually, at 10:00 a m, exhausted Akinyi was induced. She was put on a drip and upon the third one, the baby managed to get out, appearing very weak. ’After about 10 minutes, I saw, from where I was waiting outside the delivery room, the nurses wheeling an oxygen cylinder hurriedly. They tried to resuscitate him and I saw several nurses running into the room. At the corridor where I stood and I tried to talk to them but no one was talking to me. A while later, I heard a cry from the labour ward and it hit me that we must have lost the baby. Then I rushed into the labour ward and found him, still warm but without breath.’

Their healthy son who weighed 3.5 kilogrammes at birth, died as a result of foetal distress. This could have been as a result of excessive strain on the baby as he struggled to get his way out or decreased blood supply to the placenta, says Dr. Sikolia Wanyonyi,  an obstetrician-gynecologist at the Aga-Khan University Hospital (AKUH).

Normal labour is when the cervix dilates up to three centimeters during the latent phase of labour and fully dilates up to 10 centimeters in the active phase until the baby comes out. The uterus takes an hour or less to dilate one centimeter.

Prolonged labour occurs when the combined duration of both the latent and active phases of labour are more than 18 hours. It can be that the cervix dilates up to four centimeters in the active phase of labour and no other activity takes place for over six hours. It can also be that the cervix fully dilates up to ten centimeters and the baby does not descend or is obstructed and takes too long to come out.

There are four factors known to prolong labour during delivery. Dr. Wanyonyi refers to them as the 4Ps – the Passenger, the Passage, the Power and the Psyche. He explains that the 4Ps are also the parameters that gynecologists and mid-wives look out for during delivery.

‘The baby is the Passenger end what we look out for is its size, and his positioning especially in the latter stages of pregnancy and during labour.’ In developing countries, Kenya included, a baby is termed big if they weigh 4 kilogrammes or more at birth, whereas in the developed world a baby is termed big if the birth weight is 4.5 kilogrammes and above.

The Passage is the pelvis. A ‘lady pelvis’ is wide enough and this creates room for the baby to pass through. ‘But unfortunately, 45 per cent of African women do not have a ‘lady pelvis’ and therefore are faced with a challenge of a small passage when it comes to normal delivery’ Tumors in the pelvic area or the lower part of the cervix can also greatly affect labour.

The Power is the effectiveness of the uterine contractions. Dr. Wanyonyi says that at least there should occur three uterine contractions every 10 minutes of active labour with each running close to 10 seconds.

The Psyche includes how well prepared the mother is to face labour and the support system that she is getting from the partner or her immediate relatives and friends.

Management of prolonged labour

What happens when either of these four parameters is faced with a challenge and labour is prolonged?

A reprieve is that either of them can be fixed. Dr. Wanyonyi says. If stage one of labour is prolonged, what the medical personnel do is to administer pain relievers and keep the mother waiting for a while as she is being monitored. If it prolongs further, labour can be induced.

But if labour is in the active phase and the doctor notices that it is prolonging, the mother is examined on how she is coping. The contractions are also examined on frequency and length. ‘This is done by the use of the hand and a clock With the hand, the doctor can feel the position of the baby and is able to tell whether he is moving down well and to the right posit ion,’ Dr. Wanyonyi explains.

If contractions are less, the doctor can administer an oestrogen hormonal injection, “but care should be taken as oxytocin causes very strong contractions and this can cut blood supply to the placenta, harming the baby.’

Dr. Wanyonyi maintains that the hormonal injection should be used after carefully assessing that the baby is okay health-wise and care should be taken so that it does not rupture the uterus.

The baby’s heartbeat should also be checked ‘Between 110 and 160 is normal; some figure below or above that should raise concern.'”

A vaginal exam that includes checking for the coloration of the waters should be done. ‘If clear, the baby is okay. If smelly, then something is not right. The baby might be in danger. Then by the use of the fingers, the cervix is checked if it’s opening and thinning out. The length of the cervix should also be checked as it should reduce as labour progresses.

If the mother has been pushing for too long, delivery can be done by the use of a vacuum-tube extractor or forceps. Delivery by use of vacuum is very common but forceps is used only in select cases. ’We use it here and it is very safe for the baby as it is able to alter the position of the baby if badly presented. But the mother must be given some good pain relievers,’ Dr. Wanyonyi asserts. ’The vacuum too has some good success rate as it is very safe for the mother unlike the forceps which can cause some bruises.’

When labour is prolonged, a baby struggles to come out of the birth-canal safely. But there are instances when the baby suffers a lot of distress in the course of this struggle and that is why immediately after delivery, the baby might be admitted to the neonatal intensive care unit for monitoring.

This form of distress, Dr. Wanyonyi says, can affect the child’s future development if not property handled ‘It can lead to learning disabilities and delayed milestones,’ he points out. In severe cases, it can account for child-mortality and maternal-mortality due to over-bleeding for long hours.

Of importance though is that walking around and practicing some breathing exercises, especially in the last trimester can enhance the labour process. ‘A mother does not need to lie down to deliver, she can do so while standing or squatting.’ the doctor advises.

Prolonged labour can be prevented by the use of the partograph – a chart that doctors use to assess the progress of labour and identify when intervention is necessary. The chart is universally used as a medical tool around the world, including in Kenya. ‘But the challenge is that some of our hospitals have limitations and know what they can handle in labour and what they cannot, but they do not want to refer. That is why it is good for people to survey if a hospital can go beyond basic maternity care and administer emergency maternity care it the necessity arises,” Dr. Wanyonyi concludes.

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