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NORMAL LABOUR &

PARTOGRAM

LABOUR
Definition:
Occurs as a result of a physiological chain of events
within the:
1. Myometrium
2. Decidua (endometrium)
3. Cervix
.Uterine contractility:
-Braxton Hicks contractions contractures long
lasting low frequency
-Contractions: high intensity high frequency
.Cervix: Biochemical connective tissue changes
effacement (complete or incomplete)and dilatation.
.Rupture of membranes

Birth of a baby
A normal process, usually doesnt
require assistance
But potential problems +
complications .:. Supervision needed
(clinic; home; hospital)
Two processes: labor and delivery

Diagnosis of Labour
Describe the onset in detail to the px:
Show:
passage of mucus with bright red blood (1525ml)
Usually preceding regular contractions
Is a result of separation of the mucus plug
(OPERCULUM) that occludes the cervix

Contractions: painful and regular


ROM

Induction of labor the above not true


Artificial initiation: membranes artificially
ruptured; contraction medically induced)

Admit to labour ward history


examination (abdominal; vaginal)
Investigations (bp; urine)
If rectum full enema
contraindications: Advanced labour
and APH
Hand over to snr. doctor or midwife to
evaluate labour
Continue to inform the partner and px
of progress or problems

TRUE vs. False Labour


False Labour:
IRREGULAR painful contractions BUT no
cervical changes (effacement and
dilatation)

True Labour:
Big 3 (cervical changes, regular
contractions, ROM)

The transition from false to true =


Potential Labour

Stages of labour
1st stage
From the onset of labour to full dilatation
of the cervix.
Latent phase:
Onset to full effacement (4cm cervix)
PrimiG = 8 hr; MultiG = 6 hours

Active phase:
Dilatation of the cervix from 4cm-10cm.
Normal labour needs a rate of 1cm (PrimiG) to
1,5cm (MultiG) per hour.
If the rate is slow, search for the cause (look at
the 5 Ps).

Stages of labour
2nd stage
From full cervical dilatation to delivery of the
foetus.
Phase 1:
From full dilatation until the presenting part reaches
the pelvic floor .:. Baby is in descent
Uncomplicated birth = No intervention is necessary
Complicated birth at this stage = maternal exhaustion
or foetal death

Phase 2:
When the presenting part reaches the pelvic floor
pressure on the pelvic floor muscles triggers a reflex
and causes an involuntary urge to bear downFerguson reflex.

Stages of labour
3rd stage
From the delivery of the baby to the
delivery of the placenta.
Requires active management to prevent
PPH.

MECHANISM OF LABOUR

A series of changes in the foetal


position during its passage through
the birth canal.
Continuous mechanical process,
divided into multiple steps.

The Mature Fetus


Haase
Rule:

1st 20weeks of gestation, age can be


determined by the
2nd 20weeks of gestation, age can be
determined by: length (cm) 5

Baby has two ovals: head + body


Head: AP diameter is greater
Body: Transverse diameter is greater

Foetal Skull
Greatest diameter; least compressible; most
frequent presenting part; most prone to injury
The more premature the bigger the head:body
Base of skull is well ossified
Vault of skull thin, poorly ossified, joint by
membrane .:. Capable to Mould (skull bones
overlap during delivery)
Sutures facilitate moulding:
Sagittal: longitudinal
Lambdoid: transverse and posterior
Coronal: transverse and frontal
Frontal: anterior continuation of the sagittal suture

Fontanelles:
intersection of two sutures
If bulging = raised ICP; if depressed =
dehydration
Bregma: anterior, diamond shaped, closes
18months after birth
Lamda: posterior, triangular, closes 6 to 8
weeks after birth

Landmarks:
Occiput
Vertex (crown): part between the 2 fontanelles
Sinciput: between the bregma and glabella +
orbital ridges
Mentum

Transverse Diameters:
Bi-parietal: 9.5cm; largest transverse
diameter; posterior
Bi-temporal: 8cm; smallest transverse
diameter; anterior

AP Diameters:
Well flexed head: suboccipito-bregmatic
(9.5cm)
Military position: occipito-frontal (11cm)
Partial extension: mento-vertical (13.5);
face presentation; normal delivery not
possible
Complete extension: submentobregmatic (9.5cm)

Terminology
1. Lie:
Relationship of the long axis of the foetus to the
mother.
Longitudinal: long axis of the baby is the
same as the mother (99% of pregnancies)
Transverse:
the long axis of the fetus is perpendicular the long
axis of the mother (0.5% of pregnancies)
External Cephalic Version
Easy for cord to prolapse on this lie

Oblique: the longitudinal axis of the baby


iliac fossa to opposite hypochondirum (0.5% of
pregnancies.)

Terminology
2. Presentation
Foetal part that occupies the lower segment of
the uterus/ the part palpable first during vaginal
examination. Relationship of denominator
(lowest point of presenting part) to pelvis.
Cephalic presentation-96% of term
pregnancies.
Breech presentation:
3-4% of term pregnancies; 25% in early pregnancy
Footling (foot is the denom); Frank (buttock is the
denominator)

May get shoulder presentation with other lies.

Lie and presentation

Other Presentations
Compound Presentation: feeling
more than one body part
Cord presentation: the umbilical
cord can show first

Terminology
3. Foetal attitude:
The relationship of various foetal parts to each other.
Complete flexion -Foetus is in a position of
general flexion at all joints. Occiput =
denominator; Lamda = presenting part
Military attitude (Crown presentation)- Foetal
head is midway between flexion and extension; in
neutral. Occiput = denominator; Bregma =
presenting part
Partial extension: Brow = presenting part
Complete extension: Foetal head is completely
extended. Mentum = denominator; Face =
presenting part

Terminology

Foetal position

Relationship of the denominator to the four quadrants of the


pelvis.

Descent and
Engagement:
A moment within
the process of
descent when the
biparietal diameter
is at the pelvic
inlet and with 2/5
of the head
palpable above PS.
Flexion
Internal rotation
Extension
Restitution
External rotation
Delivery of the
shoulders.

Partogram
A graphical representation of the progress of
labour. Has 4 main components:
Foetal condition
Progress of labour (Cervicogram)
Maternal condition
Management and drugs

Progress of Labour
Cervical Length
Cervical Dilatation
Alert line
Action Line

Descent of the fetus in fifths


Diagnosis of Labour must be made
before a partogram is filled

Cervicogram
Dilatation, Effacement, Position of head above
pelvis.
Latent phase of 1st stage - dilatation is plotted on
the 1st vertical line.
Alert line: Plotting moved over to alert line during
active phase of 1st stage (4cm dilated)
Action line: parallel to but 2 hours after alert line.
If progression is to the right of the alert line, rule of
Ps should be applied to see the cause of poor
progression
Once causes are identified and corrected labour is allowed
to continue for 2hrs
Most important during this time is that adequate
contractions are maintained and foetal heart rate is
monitored
Adequet contractions = hallmark of progress of labour

If progression advances to the right of the


action line a normal delivery is expected
If it continues to the left, a C/S is
expected
She must be referred when the two hr
action line is crossed
In poor progression an amniontomy (to
rupture membranes) is performed to
speed up the process
However is HIV patients membranes are kept
intact as long as possible to prevent vertical
transmission

Foetal condition
CTG: Heart rate, variability, accelerations,
decelerations
Liquor: I= Intact, C= clear, B=blood stained, M=
meconium.
Station: head in relation to ischial spines.
Moulding: Extent of overlap of foetal skull bones
0= Normal; 1+ Apposed, 2+ Sutures overlap but
reducible, 3+ Not reducible.
Caput: Assess swelling of foetal head 0= Normal ,
1+= Mild swelling but compressible, 2+ Not able
to feel skull.

Partogram
Maternal Condition:
Blood pressure, pulse, urinalysis (volume,
protein, ketones, blood, glucose) &
temperature.
Management and drugs:
IV fluids, drugs

Management of labour
1st stage:
A prolonged active phase is associated with increased risk
of infection, foetal distress and uterine rupture.
Mother:
Positioning: Lie down on left side after 6-7cm dilatation
IV Fluids: if progress is poor (lasting more than 4-6hrs),
ketonuria/ abnormal foetal heart patterns develops.
Pain relief and psychological support.
Bladder: Important to regularly empty, as full bladder
can delay engagement (obstructs uterus from
comtracting)
Sterility- vaginal examinations should be limited to a
minimum.

Management of 1 stage
st

Foetus
Size and number
Lie,position and presentation.
Foetal status CTG
Labour
Amniotic fluid: fresh meconium staining (green)foetal distress.
Contractions: 3-4 contractions/ 10 mins lasting
45-60 seconds each.
PV- Membranes, cervix, foetus, pelvic size and
shape.
Record on a partogram.

Management of 2

nd

stage

Phase 2
Babys head no longer palpable above PS; Ferguson
relfelx (may be absent with epidurals); Increased pain
during contractions; decelerations are common
1. Prepare for delivery: swabbing of the vulva and
perineum, sterile draping and gowning.
2. Bimanual vaginal examination- determine the degree of
descent.
3. Local anaesthetic to the perineum- If episiotomy is
needed.
4. Empty the bladder.
5. Palpate the abdomen: During contraction, instruct the
patient to bear down (deep breath, followed by closing
of glottis and bearing down as long as possible).
6. Encourage complete relaxation between contractions.

Management of 3 stage
rd

After delivery of foetus-palpate abdomen to exclude


undiagnosed twin
Oxytocin (syntocinon) is administered immediately
thereafter IM (IV causes vomiting)
Ergot derivatives are contraindicated in hypertension or
cardiac patients

Sterile towel over mothers abdomen and another


under the buttocks.
Control bleeding (from episiotomy or arterial, by
pressure/clamping)
Look for signs indicating placental expulsion (cord
lengthening, sudden gush of blood, contraction of
uterus) to initiate active delivery by Brandt-Andrews
method.

Management of 3 stage
rd

After delivery of the placenta


Manually massage the uterus.
Clean the patient.
Episiotomy/tears-suture under local anaesthetic.
Assess the volume of blood loss, check pulse and BP.
Oxytocin, Cord traction, Uterine Massage
Always prepare for resus
If placenta is not delivered after 30min
Inject 30ml of oxytocin through the cord
Still no progress theatre

Retained placenta in previous C/S refer the


patient

Post partum care is part of the


management of labour
Observe for a minimum of 6HRS
Postnatal ward:
Px vitals
Pad check
Educate on breastfeeding,
immunizations, use of contraception

Summary
Labour is a complex physiological process.
Requires active management to prevent
maternal and foetal complications.
Partogram is an essential and useful tool in
the management of labour, if used
effectively