MANAGEMENT OF
LABOUR AND PARTOGRAPH
Dr Ogunlaja A.O. Senior Lecturer/ Obstetrician & Gynaecologist.
OUTLINE
Introduction / definition
Anatomy of female pelvis & fetal head
Process of labour
Mechanism of labour
Management of labour
Progress of labour
Abnormal labour pattern
Partograph
conclusion
To the woman He said, I will greatly multiply
your pain in childbirth, In pain you will bring
forth children; Yet your desire will be for your
husband, and he will rule over you.
Genesis 3:16
Whenever a woman is in labour she has pain,
because her hour has come; but when she gives
birth to the child, she no longer remembers the
anguish because of the joy that a child has been
born into the world.
John 16:21
INTRODUCTION
Labour is the physiological process by
which regular painful uterine contractions
result in progressive effacement,
dilatation of the cervix, and descent of the
presenting part which ultimately leads to
the delivery of the fetus and placenta
through the birth canal
The passage of the fetus through the birth
canal during labour can be unpredictable
and hazardous.
To majority of families, labour brings joy
to the families
Poor understanding and management of
labour may lead to perinatal and
maternal morbidity and mortality.
There is interplay between the 3Ps:
Power = uterine contractions
Passenger = fetus
Passage = birth canal (bony pelvis, soft
tissue of the pelvis and the perineum)
ANATOMY OF THE FEMALE PELVIS
Pelvis :- inlet or pelvic brim
mid cavity
pelvic outlet
Pelvic inlet: ant -by pubic symphysis
lat -by upper margin of pubic
bone, iliopectineal line, ala of sacrum
post- sacral promontory.
DESCENT OF THE FETAL HEAD
By vaginal examination, the lowest part of vertex has
passed or is at the level of ischial spines in absence of
caput, is said to be engaged head.
Pelvic midcavity :
Ant- middle of pubic symphysis
Lat- pubic bone, obturator fascia and inner
aspect of ischial bone and ischial spine.
Post-junction of S2 & S3.
Pelvic outlet:
Ant- lower margin of pubic symphysis,
Lat- descending ramus of pubic bone, ischial
tuberosity and sacrotuberous lig.
Post- last piece of sacrum
PELVIC DIMENSIONS
Inlet : transversely=13.5cm
AP : 11cm
Midcavity: transverse = 12cm
AP = 12cm
Outlet: transverse = 11cm
AP = 13.5cm
FETAL SKULL
Sutures are lines between the bony plates.
-sutures lines on the vault are soft,
unossified membranes.
Bones of the vault- parietal bones,
occipital bones, frontal bone and temporal
bones.
-during labour the vault bones may
overlap= moulding.
Fontanelles- junctions of sutures.
Eg. Ant fontanelle – diamond shape ( at
junction of sagittal, frontal and coronal
sutures )
post fontanelle- triangular (at junction
of the sagittal suture and lambdoidal
sutures)
Diameters of fetal skull
Well flex fetal head (vertex presentation)-
Longitudinal diameter is 9.5cm measured
from suboccipito-bregmatic diameter
With extension of fetal head the
longitudinal diameter increases.
The greatest longitudinal diameter is
mento-vertical (from mentum to vertex :
face presentation)= 13cm, too large to pass
through the pelvis
INITIATION OF LABOUR
The mechanism responsible for initiation
of labour is unknown.
Some contributory factors include:
Hormonal = prior to labour, reduction in
progesterone receptors
-increase in concentration of
oestrogen relative to progesterone
prostaglandin and oxytocin release
-maternal corticotrophin releaseing
hormone (CRH) increases in concentration
and potentiate the action of oxytocin and
prostaglandins on myometrial
contractility.
Fetal cortisol- converts progesterone to
oestrogen
Myometrial factor
Prostaglandin and oxytocin increase
myometrial intracellular free calcium ions
which results in increase in formation of
contractile actin-phosphorylated myosin
MECHANISM OF LABOUR
These are series of events (changes in
position and attitude)that occur during
the passage of the fetus through the birth
canal.
Mechanism of labour for vertex
presentation and gynaecoid pelvis
FIERE
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of the shoulders
Delivery of the fetal body
STAGES OF LABOUR
Symptoms & Signs of onset of labour:
regular abdominal pain, backache, show,
liquor drainage.
In latent phase- Palpable uterine
contractions minimum of 1 in 10min,
cervical dilatation and effacement.
1st stage- latent phase: Cervical dilatation
<4cm
-active phase :Cervical dilatation
=/>4cm
2nd stage
3rd stage
MANAGEMENT OF NORMAL LABOUR
Normal labour: when uterine contractions
begin spontaneously at term and the fetus
& placenta are delivered per vaginam
with 12hours maximum duration
irrespective of whether or not some
interventions (like oxytocin
augmentation) were required to assist or
facilitate the process.
AT PRESENTATION / ADMISSION
Biodata
Presenting complaint / History of labour
Regular uterine contraction (abd pain, back
pain, show, liquor drainage, vainal
bleeding)
History of Index pregnancy
Fetal movement
Past obstetric history
Past medical history
PHYSICAL EXAMINATION
General examination- palor, jaundice, PR,
BP
Abdominal examination-
obstetric examination
-Symphysio-fundal height
-Lie
-Presentation
-Position
-Engagement
-Fetal heart sound
VAGINAL EXAMINATION
Cervix – consistency, position,
dilatation,
effecement,
membrane intact, liquor colour
station of the presenting part
Position of the presenting part
Caput
Moulding
Adequacy of the pelvis
Basic investigation:
PCV
Urinalysis
+/- grouping & crossmatching for high
risk cases
lentiviral screening test for un-screened
pt
INTRAPARTUM MONITORING
chart on Partograph
FHR- ½ hourly
Uterine contraction- ½ hourly
Pulse rate- hourly
BP - hourly in normotensive patient
Vaginal examination- 4 hourly
Temperature - 4 hourly
Urinalysis- 4 hourly /or whenever she
passes urine
PROGRESS OF LABOUR
Assessment of progress of labour
-Uterine contraction
-Descent of the presenting part
-Cervical dilatation
ABNORMAL LABOUR PATTERNS
Primary dysfunctional labour- defined as
a labour in which the active phase
progresses at a rate of less than 1cm / hr
before a normal active phase slope has
been established.
It is usually due to inefficient uterine
contraction
Treatment – majority will respond to
oxytocin
o secondary arrest- occurs when cervical
dilatation ceases after a normal portion of
active phase dilatation.
o Causes: inefficient uterine contraction,
malpresentation / malposition, CPD
Treatment- depends on the aetiology
- oxytocin , c/s etc
dr ogunlaja a.o
Senior lecturer/obstetrician gynaecologist
INTRODUCTION
A partograph is a composite graphical record of the
observations made of a woman in labour on a single sheet of paper.
It was developed and extensively tested by the World
Health Organization (WHO 1994).
Can serve as an “early warning system” & assist in
making timely decisions on transfers (referrals),
intervention (augmentation) &/or termination of
pregnancy.
HISTORY Emanuel Friedman's partograph - 1954
Based on observations of cervical dilatation and foetal
station against time elapsed in hours from onset of
labour.
The time of onset of labour was based on the patient's
subjective perception of her contractility.
Plotting cervical dilatation against time yielded the
typical Sigmoid or 'S' shaped curve, and station
against time gave rise to the Hyperbolic curve.
Philpott and Castle – 1972
Introduced concept of "ALERT" and "ACTION" lines.
Alert line was drawn at a slope of 1 centimetre/hr for women starting at zero time i.e. time of admission .
Action line drawn four hours to the right of the alert
line showing that if the patient has crossed the alert line active management should be instituted within 4 hours, enabling the transfer of the patient to a specialised tertiary care centre.
OBJECTIVES
Early detection of abnormal progress of labour.
Prevention of prolonged labour.
Recognize cephalopelvic disproportion long before
obstructed labour.
Assist in early decision on transfer, augmentation, or
termination of labour.
OBJECTIVES (CONT..)
Increase the quality and regularity of all observations of mother and fetus.
Early recognition of maternal or fetal problems.
Highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc).
Reduce incidence of CS rate.
Facilitates handover procedure.
COMPONENTS
Part I : Patient Identification
Part II : Fetal condition
Part III : Progress of labour
Part IV : Maternal condition
Outcome ………………
Mother information
Fetal well-being • Fetal heart rate
• Character of liquor
• Moulding
Labour progress • Dilatation
• Descent
• Uterine contraction
Medications • Oxytocin
• Pain relief (e.g. pethidine)
Maternal well-being • BP, Pulse, Temperature
• Urine – albumin, glucose, acetone
• Urine output
PART I : PATIENT IDENTIFICATION
Name
Gravida
Para
Hospital number
Date and time of admission
Time of ruptured membranes.
PART II : FETAL CONDITION
Monitor and assess fetal condition
1 - Fetal heart rate
2 - Liquor
3 - Moulding the fetal skull bones
FETAL HEART RATE
Monitor every 30 minutes in latent phase.
Every 15 minutes in active phase.
Every 5 minutes in second stage of labour.
Mark it with a dot & join the lines.
Basal fetal heart rate?
< 160 beats/minutes =tachycardia
> 110 beats/minutes = bradycardia
>100 beats/minutes = severe bradycardia
MEMBRANES AND LIQUOR
Intact membranes ……………………………….. I
Ruptured membranes + clear liquor ……………… C
Ruptured membranes + meconium- stained liquor.. M
Ruptured membranes + blood – stained liquor…… B
Ruptured membranes + absent liquor……………. A
MOULDING THE FETAL SKULL
BONES
Moulding is an important indication of how adequately the pelvis can accommodate the fetal head.
Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion.
Separated bones, sutures felt easily …………….… o
Bones just touching each other …………………… +
Overlapping bones (reducible)…………………... ++
Severely overlapping bones (nonreducible) …….. +++
PART III : PROGRESS OF LABOUR
Cervical dilatation
Descent of the fetal head
Uterine contractions
Fetal position
This section of the partograph has as its central
feature a graph with a vertical scale on the left, numbered in the ascending order from 0 to 10 (Cervical dilatation in cms).
In same vertical scale – descent of the fetal head as assessed by abdominal examination.
At the right in the descending order denotes the station of the fetal presenting part.
CERVICAL DILATATION
(CONT..)
When the active phase of labor begins, all recordings are transferred and start by plotting cervical dilatation on the alert line using the letters TR.
Leaving the area between the transferred recording
blank. The broken transfer line is not part of the
process of labor.
Do not forget to transfer all other findings vertically.
DESCENT OF THE FETAL HEAD
It should be assessed by abdominal examination
immediately before doing a vaginal examination, using
the Rule of fifth ( Crichton method ) to assess
engagement.
The rule of fifth means the palpable fifth of the fetal
head is felt by abdominal examination above the level
of symphysis pubis.
When 2/5 or less of fetal head is felt above the level of
symphysis pubis, this means that the head is engaged.
FETAL POSITIONS
Occiput transverse positions
Occiput anterior positions
UTERINE CONTRACTIONS
Palpate number of contractions in
ten minutes and duration of each
contraction in seconds
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:
Observations of the contractions are made every hour
in the latent phase and every half-hour in the active
phase.
Assessed by number of contractions in a 10 minutes
period.
Measured in seconds from the time the contraction is
first felt abdominally, to the time the contraction
passes off.
Each square represents one contraction.
PART IV: MATERNAL CONDITION
Assess maternal condition regularly by monitoring:
Oxytocin – Amount per volume intravenous
fluids in drops per minute, every 30 minutes. The
Concentration is indicated in the upper box &
dosage (mIU/min) in lower box.
Drugs – Any additional drugs given.
IV Fluids – used.
PART IV: MATERNAL CONDITION
Pulse – Every 30 mins & marked with a dot (•).
Blood pressure – Recorded in vertical line every 4
hours & marked with arrows. (for cases like
preeclampsia/eclampsia blood pressure should be
checked every 15 minutes or continously if the facility
is available.)
Temperature – Recorded every 2-4 hours.
Urine volume , analysis for protein and acetone –
Everytime urine is passed.
MANAGEMENT OF LABOUR
USING THE PARTOGRAPH
- LATENT PHASE IS LESS THAN 8 HOURS
- PROGRESS IN ACTIVE PHASE REMAINS ON
OR TO THE LEFT OF THE ALERT LINE.
Precaution to take in labour
management. Do not augment with oxytocin if latent and active
phases go normally.
No ARM in latent phase.
ARM at any time in active phase.
Between alert and action
lines
In health center, the women must be
transferred to a hospital with
facilities for caesarean section, unless
the cervix is almost fully dilated.
Observe labor progress for short
period before transfer.
Continue routine observations.
ARM may be performed if membranes
are still intact.
At or beyond action line
Conduct full medical assessment.
Consider intravenous infusion / bladder
catheterization / analgesia.
Options
- Deliver by caesarean section if there is
fetal distress or obstructed labour.
- Augment with oxytocin by intravenous
infusion if there are no contraindications.
ABNORMAL
PROGRESS OF
LABOR
“ One of the main functions
of the partograph is to
detect early deviation
from normal progress of
labor. “
PROLONGED ACTIVE PHASE
In the active phase of labor, plotting of cervical dilatation will normally remain on or to the left of the alert line.
Moves to the right of the alert line warns that labor may be prolonged.
Happens if the rate of cervical dilatation in active phase of labor is less than 1cm/hour for a minimum of 4hrs.
At the action line, the woman must be carefully reassessed for why labor is not progressing and a decision made on further management.
SECONDARY ARREST OF CERVICAL
DILATATION
When the cervical dilatation commences normally but
stops or slows significantly for 2 hours or more prior to
full dilatation of cervix.
THANK YOU