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