MANAGEMENT OF LABOR

ABNORMAL LABOR
DETECTION USING THE
PARTOGRAPH
Categories of labor
First and second stage

 First Stage: from labor onset until full dilation

 Latent phase: period from onset till labor becomes active
 Initiation of regular painful contractions
 Onset is difficult to identify objectively
 Usually depends on patient memory
 Active phase: accelerating slope of cervical dilation till full
 Diagnosis:
 ≥80 percent effacement
 ≥4 cm dilation of the cervix
 Second stage:
 Full dilation until delivery of the baby
Monitoring progress of labor
 Cervical effacement: length of remaining cervix in cm (0-3cm) or
percentage:
 0% effacement refers to at least a 2 cm long, or a very thick cervix
 100% effacement refers to no length remaining or a very thin cervix.
 Generally, ≥80% effacement is required for the diagnosis of active
labor.
 Cervical dilation: from closed or 0 cm dilation to complete or 10
cm dilated.
 A single index finger is equal to 1 cm / 2 fingers dilation is equal to 3
cm.
 10 cm (completely dilated): no cervix palpated around the presenting
part
 Station: progress in descent
 Position: progress in rotation
 Like station position critical before performing an operative vaginal
delivery
 Caput obscures sutures
Duration of the First stage of
labor

Primigravidas Multiparas

Average Upper Average Upper

Normal Normal
Latent phase hrs 8.6 20 5.3 14
Active phase hrs 5.8 12 2.3 6
First stage hrs 13.3 28.5 7.5 20
Rate of Cervical dilatation in 1.2 1.5
active phase

Active phase cervical dilatation rates (5th

percentile):
Multiparous: 1.5 cm
Nulliparous: 1.2 cm

Generally: at least 1 cm per hour

Duration of second stage
of labor

95th percentile for length of second stage Epidura use

No Yes
Nullipara 2 h 3h
Multipara 1 h 2h

Prolonged second stage

 No excess neonatal morbidity with prolonged second
stage in the absence of NRFH:
 After 4 hours, the likelihood of vaginal delivery declines
while maternal morbidity increases.
Factors affecting duration of first & second
stage of labor

 parity
 maternal body mass index,
 fetal position: increased with fetal position other than
OA
 fetal size: increased with maternal body mass index
 Epidural
 Continuous doula support: Shorter length of labor
 Reduced use of analgesia, oxytocin, and
operative or cesarean delivery
 Active management of labor:
 Admission in active phase of labor (probably)
 Maternal position (second stage)
 Delayed pushing (second stage)
Prolonged first & second
stage:

 CPD/ FPD

 Malpositions (rotation to OA) and

malpresentation

 Poor uterine contractions

Wrong diagnosis:
• Latent stage
 Soft tissue • Active FSOL
• Second SOL
 Cervical (FSOL)
 Perineum (SSOL)
Categories of labor
Third stage:

• Delivery of baby until delivery of the placenta

• Median duration:
• 6 minutes
• exceeded 30 minutes in 3% of women
• Duration not affected by parity
• 30 minutes associated with increased risk of:
• > 500-ml blood loss,
• > 10% drop in post-delivery hematocrit
• need for D&C
Physiology of placenta separation
Management of
SPONTANEOUS VAGINAL DELIVERY

 Goals of assistance:

 reduction of maternal trauma,

 prevention of fetal injury,

 initial support of the newborn, if

required
Supports needed:

First stage of labor

 Admission Criteria
 Low risk and intact membrane – admit in active phase (cervix
 3cms)
 Early admission
 High-risk pregnancies (admitted earlier or as labor starts)
 Ruptured membranes, pre-eclampsia etc
 Difficulty in access facility
 Can assume any position comfortable to her
 Fluid diet: small sips of sweetened tea or water)
 NPO for high risk (CS)
 Emotional support
 Pain and breathing
 Partner/ Duala support
Supports needed:
Second stage of labor

At crowning:
 Gentle pressure to

maintain flexion
and control delivery
May protects
perineal injury

 Episiotomy
Second-degree tear
Types:
 Mediolateral
 Median (midlin)
 Supports needed:

Second stage of labor

Episiotomy
Routine not recommended
Indicated to expedite delivery
in:
•NRFHR
•relief of shoulder dystocia etc
Adequate analgesia
•Local
•Regional
 Complications:
• increased blood loss (if too early)
• fetal injury,
• Localized pain
• May lead to 3rd /4th degree tear-
median
Supports needed:
Second stage of labor

 External rotation: allowed for spontaneous restitution

 Check nuchal umbilical cords:
Reduce: if not possible, doubly clamped and transected
 No routine DeLee suction
Supports needed:
Second stage of labor

 Anterior shoulder delivery;

 gentle downward
traction with maternal
expulsive efforts

 Posterior shoulder
delivered:
 upward traction with
minimal force possible
to avoid perineal injury
and traction injuries to
the brachial plexus

Held the NB securely and place on the mother's abdomen and

wiped dry
Support needed in

Third stage of labor

 EXPECTANT  ACTIVE √
- no oxytocin - Oxytocin im

- waiting for signs of - controlled traction of

separation and cord and counter
placenta is delivered traction on uterus
by gravity and Early clamping is dropped from WHO’s
woman’s effort guidelines
Delay until pulsation stop?
Pulse may continue for 3 min but
- cord is clamped transfusion may not be of clinical
significance
when pulsation ceases No evidence of increased risk of clinical
or after delivery of jaundice
placenta HIV infection and delayed cord-
clamping, an issue?
Active management of third stage of labour (1)

 Give oxytocin immediately:

 Palpate uterus to rule out the possibility of
an additional baby
 Administer oxytocin 10 units im (within one
minute after delivery)
Active management of third stage of labour (2)

 Why oxytocin?
 Effective (2-3 minutes) & stable
 Minimal side effects if any in AMTSL:
 Direct IV bolus & hypotension
 Water retension in induction/augumentation with IV fluid
 Can be given to all women

 If oxytocin is unavailable ?
 Ergometrin 0.2 mg im: NOT in high blood pressure
 Misopristol (PG): Inexpensive, stable at room temperature,
administered orally, rectally, can be used in hypertension
Active management of third stage of labour (3)

Clamp the cord

 Clamp the cord close to

the perineum using

sponge forceps.
 Hold the clamped cord

and the forceps with one

hand.
 Keep slight tension on the

cord and await a strong

uterine contraction (2-3
minutes).
Active management of third stage of labour
(4)

Controlled cord
traction
 When the uterus becomes
rounded or the cord
lengthens:
 Very gently pull
downwards on the cord.  Never pull on the cord
AND without pushing the
 Place the other hand just uterus up with the
above the woman’s pubic other hand.
bone and stabilize the  CCT helps prevent
uterus by applying counter inversion of the
traction during controlled uterus.
cord traction.
Active management of third stage of labour
(4)

Controlled cord traction

 If the placenta does not descend during 30-40 sec of
controlled cord traction (i.e. there are no signs of
placental separation), do not continue to pull on the
cord.
 Gently hold the cord and wait until the uterus is well
contracted again. If necessary, use a sponge forceps to
clamp the cord closer to the perineum as it lengthens.
 With the next contraction, repeat controlled cord
traction with counter traction.
 Manual removal and or extraction of the placenta is
indicated after 30 minutes (or earlier in PPH)
Active management of third stage of labour
(5)

Controlled cord traction

 If the placenta does not descend during 30-40 sec of CCT,
do not continue to pull on the cord.

 Gently hold the cord and wait until the uterus is well
contracted again.
 If necessary, use a sponge forceps to clamp the cord closer to the
perineum as it lengthens.

 With the next contraction, repeat controlled cord traction

with counter traction.

 Manual removal and or extraction of the

placenta is indicated after 30 minutes (or
Delivery of placenta from
vagina

Slowly pull to
complete the
delivery:

 Receive placenta in
cupped hands

 Gentle up-and down-

movements with
placenta to deliver
membranes
Examination of placenta, umbilical cord,
and fetal membranes (1)

 The site of insertion of the umbilical cord into the placenta should
be noted.
 Abnormal insertions include
 marginal insertion (cord inserts into the edge of the placenta)
 membranous insertion (vessels of the cord course through the
membranes before attachment to the placental disk)
 The cord itself should be inspected for:
 Length: average cord length is 50 to 60 cm
 correct number of umbilical vessels
 Normally two arteries and one vein
 A single umbilical artery is associated with other fetal
structural anomalies in 27% of cases: need for thorough
examination of NB
 true knots,
 hematomas,
 strictures
Examination of placenta, umbilical cord,
and fetal membranes (2)

 Examine fetal and maternal surfaces of

the placenta:
 Fibrosis, infarction, calcification
 extensive lesions prompts histologic
examination
 Adherent clots: recent placental
abruption
 absence does not exclude abruption
 If a portion of the maternal surface of
the placenaa is missing or there are torn
membranes with vessels, suspect
retained placental fragments
 missing succenturiate lobe
 No routine manual exploration of uterus
unless suspicion of retained products of
conception or PPH
Placenta, umbilical cord, and fetal
membranes examination (3)
 Placental weight (without membranes, cord) varies with NB
weight
 ratio of approximately 1 : 6
 Large placentae: hydrops fetalis, congenital syphilis etc

 At end of the third stage

 Check for excessive bleeding
 Make sure no clot in vagina
 Make sure that the uterus is well controlled
Support of

Fourth stage of labor

 Massage the fundus of the uterus through

the woman’s abdomen until the uterus is
contracted.
 Repeat the uterine massage every 15 min
for the first two hours – (teach the mother
how to do it)
 Ensure that the uterus remains hard after
you stop uterine massage.
 Unless the NB needs neonatal admission,
keep the NB close with the mother
 Initiate breast feeding unless alternative
arrangements are made
Support of

Fourth stage of labor

 Massage the uterus

 Immediately massage the fundus of the
uterus through the woman’s abdomen until
the uterus is contracted.
 Repeat the uterine massage every 15 min
for the first two hours.
 Ensure that the uterus remains hard after
you stop uterine massage.
PARTOGRAPHIC MONITORING OF
LABOUR
Advantage of using partograph:

 Prolonged labor decreased from 6.4% to 3.4%

 Augmentation decreased from 20.7% to 9.1%

 Emergency C/S rate decreased from 9.9% to 8.3%

 Intrapartum stillbirth decreased from 0.5% to

0.3%

Others
 continuous documentation

 timely referral

 quality of care Lancet, 1994

Partograph is used to
monitor
1. progress of labour
2. Maternal condition
3. Fetal condition
Change made on first WHO partograph

Latent AND Active phase Active phase only

Information required upon admittance

Mrs. X 3 2
12.12.07 04.35 am 03.10
Dilatation of cervix
 Cervix dilatation –”speedy” vs. “normal” vs.
“slow” progress

08.00

10.00

15.00
05.0
0

Cervical dilatation of 1 cm/hour = progress of labour follows the alert line

1 cm/hour = progress line moves to the left of the alert line = ”speedy”
progress
< 1 cm/hour = progress line moves to the right of the alert line, moving
35
towards or passing the action line – slow or prolonged progress
Uses of old version of the partograph …
Cervix dilatation from latent to active phase

X X

21:00
18:00
19:00

22:00
20:00
15:00
16:00

18:00
14:00

17:00

36
Descent of foetal head determined by
abdominal examination

Head is Head is one hand

loose over width over the
the pelvic pelvic brim
brim = 5/5

Head is Head is two finger

moulding width over the
= 2/5 pelvic brim

37
Assessing descent of head by vaginal examination
Descent of foetal head

08.00
05.0
0

39
Recording the contractions’ strength i.e.
duration in seconds

< 20 secs duration

20-40 secs duration

> 40 secs duration

40
Information about foetal status in labour

Mrs X 3 2
12.12.07 04.35 am 03.10

Amniotic  I – membranes intact

liqour  C – clear amniotic fluid
 В – blood-stained amniotic fluid
“I”,  A – absence of amniotic fluid
“C”“M”  M – meconium-stained amniotic
“B”, “A” fluid
Information about foetal status in labour

Mrs X 3 2
12.12.07 04.35 am 03.10

Moulding

“O”, “+”
“++”, “++
43
+”
 Information about maternal status in labour

Pethidine 2% 2
ml

36,
7
Maternal
temperatur
e 50 ml

44
Abnormal progress of labor
Abnormal
progress of labor
Abnormal
progress of
labor