Management of normal labour and partogram

Management of normal labour and partogram by Prof. Athula Kaluarachchi

1. Management of Normal Labour and partogram Prof Athula Kaluarachchi Faculty of Medicine University of Colombo Reproductive Health Module

2. Explain the physiology of normal labour Describe signs and symptoms Explain the mechanism Discuss the stages of normal labour Management of different stages of Normal labour Partogram How to maintain a partogram How to detect abnormal labour conditions Objectives Reproductive Health Module

3. WHO definition of normal labour . "Spontaneous in onset, low-risk at the start of labour and remaining so throughout labour and delivery. The infant is born spontaneously in the vertex position between 37 and 42 completed weeks of pregnancy. After birth, mother and infant are in good condition." Normal Labour Reproductive Health Module

4. Diagnosis Labor is a clinical diagnosis, which includes ( i ) the presence of regular phasic uterine contractions increasing in frequency and intensity, and (ii) progressive cervical effacement and dilatation. A show (bloody discharge) may or may not be present. Reproductive Health Module

5. The ability of the fetus to successfully negotiate the pelvis during labor and delivery depends upon a complex interaction of three variables: power (uterine contractions), passenger (fetus), and passage (both bony pelvis and pelvic soft tissues). Reproductive Health Module

6. Reproductive Health Module

7. Labour Physiology  Labor is a physiological event involving a sequential, integrated set of changes within the myometrium , decidua , and uterine cervix that occur gradually over a period of days to weeks. Biochemical connective tissue changes in the uterine cervix appear to precede uterine contractions and cervical dilation, and all of these events usually occur before rupture of the fetal membranes. Reproductive Health Module

8. Term labor may be regarded physiologically as a release from the inhibitory effects of pregnancy on the myometrium , rather than as an active process mediated by uterine stimulants. Strips of myometrium obtained from a quiescent uterus at term and placed in an isotonic water bath will contract vigorously and spontaneously without added stimuli . Both inhibitory and stimulatory mechanisms likely play a role in uterine activity. Reproductive Health Module

9. PHYSIOLOGICAL PHASES OF MYOMETRIAL ACTIVITY — The regulation of uterine activity during pregnancy can be divided into four distinct physiologic phases Phase 0: inhibitors active — Throughout most of pregnancy the uterus is maintained in a state of functional quiescence through the action of various putative inhibitors including, but not limited to: ●Progesterone ● Prostacyclin (prostaglandin I-2) ● Relaxin ●Parathyroid hormone-related peptide ●Nitric oxide ● Calcitonin gene-related peptide ● Adrenomedullin ● Vasoactive intestinal peptide. Phase 1: myometrial activation — As term approaches, the uterus becomes activated in response to uterotropins , such as estrogen. This phase is characterized by increased expression of a series of contraction-associated proteins ( CAPs ) (including myometrial receptors for prostaglandins and oxytocin ), activation of specific ion channels, and an increase in connexin -43 (a key component of gap junctions). An increase in gap junction formation between adjacent myometrial cells leads to electrical synchrony within the myometrium and allows for effective coordination of contractions. Phase 2: stimulatory phase — Following activation, the "primed" uterus can be stimulated to contract by the action of uterotonic agonists, such as the stimulatory prostaglandins E2 and F2 alpha and oxytocin . Phase 3: involution — Involution of the uterus after delivery occurs during phase 3 and is mediated primarily by oxytocin . Reproductive Health Module

10. Initiation of Labour Reproductive Health Module

11. Reproductive Health Module

12. First Stage – Onset of labour to full dilatation of cervix Latent phase Active Phase Second Stage – Full dilatation to delivery of the baby propulsive phase (when the head descends to the pelvic floor) expulsive phase (when the mother experiences a desire to push until the baby is delivered) Labour – 3 stages Reproductive Health Module

13. Third Stage - delivery of the baby to delivery of the placenta Reproductive Health Module

14. Mechanism of Normal labour Reproductive Health Module

15. Definitions: Latent phase of the first stage of labour – from the commencement of labour to a cervical dilatation of up to 4 cm. Active phase of the first stage of labour – commences at a cervical dilatation of 4cm and ends with full dilatation. (There are regular painful contractions and progressive cervical dilatation from 4cm up to full dilatation) First Stage Reproductive Health Module

16. General considerations Communication between women and healthcare professionals/workers Greet the mother Treat her with respect and dignity Assure privacy Establish a good rapport Maintain a calm and confident approach Assess the woman’s knowledge of strategies for coping with pain Ask her permission before all procedures Management of labour Reproductive Health Module

17. Shaving or trimming of perineal hair may be necessary to facilitate unhindered performance and repair of the episiotomy. Where an enema is deemed necessary, a medicated enema is recommended. (These two steps should not be considered mandatory) Women should be encouraged to have a companion of her choice during labour, depending on the facilities and clinical situation. Preparation of mothers to transfer to labour room Reproductive Health Module

18. Mobilization and positioning Women should be encouraged and helped to move about and adopt whatever positions they find most comfortable throughout labour. Eating and drinking in labour Mothers must be encouraged to consume clear, non-fizzy liquids during labour. Isotonic solutions such as oral rehydration fluid and coconut water are more beneficial than water. In addition to clear fluids, women in the latent phase may consume light solids e.g. biscuits and fruits. Reproductive Health Module

19. Latent phase It is important to recognize the latent phase of labour, since its prolongation could lead to maternal exhaustion, dehydration and acidosis, leading to fetal compromise and dysfunctional labour. Women in the latent phase of labour would be best managed in the antenatal ward. Management of the first stage of labour Reproductive Health Module

20. Check the fetal heart and maternal pulse half hourly; Check temperature four hourly; Consider vaginal examination four hourly, depending on the contraction pattern and initial cervical dilatation; Document the colour of amniotic fluid if the membranes rupture; Use of a sanitary pad may indicate early the presence of meconium . Consider the requirement for analgesia. Women in the latent phase of labour must be assessed on a regular basis, as follows: Reproductive Health Module

21. The latent phase is considered prolonged when it lasts more than 12 hours in a primigravida and 8 hours in a multigravida . Reproductive Health Module

22. Admitting women to the labour room All pregnant women diagnosed as being in active phase of the first stage of labour need to be admitted to the labour room. The initial assessment and management of a woman at the labour room should include: Listening to her story, considering her emotional and psychological needs and reviewing her clinical records Physical observation: temperature, pulse, blood pressure Management of the Active phase Reproductive Health Module

23. Length, strength and frequency of contractions Abdominal palpation: fundal height, lie, presentation, position and station Vaginal loss: show, liquor (Clear or Meconium ) blood Assessment of woman’s pain including her wishes for coping with labour along with the range of options for pain relief Reproductive Health Module

24. The fetal heart rate (FHR) should be auscultated preferably with a hand held Doppler for a minimum of 1 minute immediately after a contraction(every 15 min) The maternal pulse should be recorded to differentiate between maternal pulse and FHR • Vaginal examination four hourly or earlier, depending on the clinical situation; • Reproductive Health Module

25. Reproductive Health Module

26. Frequency of contractions should be monitoredas follows: The interval between two contractions should be assessed by palpation of the abdomen. During active labor usually there are at least three contractions per ten minutes. Encouraged to continue consuming clear fluids Support by the labour companion Reproductive Health Module

27. Delayed progress of active phase is diagnosed when there is progress of less than two cm in four hours. Slowing of progress in a woman who has previously been progressing satisfactorily must also be considered as a delay. Reproductive Health Module

28. Passive second stage of labour Full cervical dilatation is reached in the absence of involuntary expulsive efforts Intermittent auscultation immediately after a contraction for at least one minute, at least every 10 minutes. The maternal pulse should be palpated if there is suspected fetal bradycardia or any other FHR anomaly to differentiate the two heart rates. Presence of meconium must be noted. Management of second stage of labour Reproductive Health Module

29. Diagnosed when the mother gets the urge to bear down with full dilatation. Intermittent auscultation of the fetal heart should be done immediately after a contraction for at least one minute, at least every 5 minutes. The maternal pulse should be palpated if there is fetal bradycardia or any other FHR anomaly. Presence of meconium must be noted. Active second stage of labour (expulsive phase) Reproductive Health Module

30. Chart BP and PR hourly Continue 4hrly temperature chart Half hourly documentation of frequency of contractions Consideration of the woman’s emotional and psychological needs Observations second stage of labour: Reproductive Health Module

31. Primigravida : Birth would be expected to take place within 2 hours of the start of the active second stage A diagnosis of delay in the active second stage should be made when it has lasted 1 hour and need to seek the advice. Duration –Second Stage Reproductive Health Module

32. Multigravida: Birth would be expected to take place within 1 hour of the start of the active second stage A diagnosis of delay in the active second stage should be made when it has lasted 30 minutes Delay in the second stage in a multiparous woman must raise suspicion of disproportion or malposition. Duration –Second Stage Reproductive Health Module

33. Reproductive Health Module

34. Period from complete delivery of the baby to the complete delivery of the placenta and membranes Third stage of labour Reproductive Health Module

35. 1. Routine use of utetotonic drugs: Oxytocin 5 IU intravenously soon after the delivery of the baby or 10 IU intramuscularly 2. Delayed cord clamping (2 minutes after the birth) and cutting of the cord 3. Followed by controlled cord traction. This must be followed by uterine massage. Active management of the third stage of labour Reproductive Health Module

36. Inspect for continued fresh bleeding Check pulse, blood pressure, uterine contraction and the level of the fundus every 15 minutes up to 2 hours Her general physical condition, as shown by her colour, respiration and her own report of how her feels Observations in the immediate postpartum period Reproductive Health Module

37. • Continuing fresh bleeding; • Elevation of the level of the fundus ; • Increase of pulse rate above 100 or by 30 beats per minute; • Drop in systolic blood pressure below 100 or by 30 mmHg. Experienced medical personnel should be informed if: Reproductive Health Module

38. Delayed third stage is diagnosed if the placenta is not delivered within 30 minutes of active management Delayed third stage Reproductive Health Module

39. Delayed clamping of the cord allows for placental transfusion, which reduces neonatal and infant iron deficiency and anemia. This policy should be followed unless the baby is born in a poor condition or if the mother is bleeding or is Rhesus isoimmunized Delayed clamping of the cord Reproductive Health Module

40. Reproductive Health Module

41. Reproductive Health Module

42. Reproductive Health Module

43. Reproductive Health Module

44. Reproductive Health Module

45. Maintaining the new partogram Reproductive Health Module

46. P artogram : Is a graphic representation of the events of labour All the observations made on the mother and the fetus are plotted in one sheet H elps in early recognition of abnormal labour and fetal distress. Reproductive Health Module

47. Time of Vaginal Examination Information of the mother N ame Age BHT number POG Gravidity Parity Blood group Date & Time Special problems Special instructions Reproductive Health Module

48. First stage of labour FHR (every 30 mins in latent phase /every 15 mins in active phase) CTG information- N / S / P Duration of a contraction and contraction free interval Dose and rate of oxytocin infusion (drops/min or ml/min) Reproductive Health Module

49. Digital vaginal examination Cervical descent Liquor - C/M/B/ Ab Membranes intact - I Position Caput Moulding - 0 / + /++ / +++ Abdominal descent of fetal presenting part Cervical dilation ⊙ Reproductive Health Module

50. Mother’s observations Pulse rate Blood pressure Temperature Actions taken Reproductive Health Module

51. Time at full cervical dilation and commencement of pushing Second stage of labour Fetal heart rate (every 10 minutes during passive phase/ every 5 mins in expulsive phase) Reproductive Health Module

52. When should the p artogram be started? I f the frequency of uterine contractions is 2 or more per 10 minutes or A t induction of labour with oxytocin or by amniotomy Reproductive Health Module

53. Frequancy of recording the fetal heart rate From onset of labour to cervical dilation of 4cm every 30 minutes From cervical dilation of 4cm to 10cm every 15 minutes From cervical dilation of 10cm to onset of pushing (during the passive phase of second stage) every 10 minutes From onset of pushing to delivery of the baby (active phase of the second stage) every 5 minutes Reproductive Health Module

54. Sd look at the above example If a CTG is carried out, findings are to be documented as N normal S suspicious P pathological example of a FHR recording If a CTG is carried out, findings to be documented as; N (normal ) S (suspicious ) P (pathological) Commencement of the active phase of the second stage Reproductive Health Module

55. Documenting labour contractions This needs to be done every 30 minutes Document the sum of ‘duration of a contraction and the interval between two consecutive contractions ’ < Duration less than 20 S between 20-40 S between 40-60 S Duration of a contraction Interval between two consecutive contractions Reproductive Health Module

56. Duration of a contraction = < 20 s Contraction free interval = 5mins Duration of a contraction = 20 s – 40 s Contraction free interval = 3mins Duration of a contraction = 40 s – 60s Contraction free interval = 1min Reproductive Health Module

57. Documentation of cervical dilation Alert line - to be drawn (1 cm per hour) from the first detection of a cervical dilatation of 4 cm or more Action line - to be drawn ( 1cm per hour ) 4 hours to the right of the alert line Reproductive Health Module

58. E.g.: cervical dilation was 5cm when the partogram was started. S ee how the action and alert lines have been drawn I n this example partogram has started when cervical dilation was 5cm. Look how the alert line was drawn from the point where cervical dilation was more than 4cm for the first time. 10 9 8 7 6 5 4 3 2 1 4 hours Alert line Action line Cervical dilation abdominal descent Cervical dilation Abdominal descent Reproductive Health Module

59. D escent of the fetal head on abdominal palpation Reproductive Health Module

60. Documentation about the colour of liquor I ( Intact membranes ) C ( Clear ) M ( Meconium) B ( Blood stained ) A ( Absent ) Degree of moulding to be documented as: 0 Bones separated , suture lines felt easily. + Bones just touching each other ++ Bones overlapping +++ Bones overlapping severely suTURES Reproductive Health Module

61. Maintaining the partogram during the second stage of labour Reproductive Health Module

62. Section to be used in the second stage Time of full dilation Time of commencement of pushing Time of full dilatation & Time of commencement of pushing ( ) should be recorded Reproductive Health Module

63. second stage of labour During the intrapartum period ( during both first and second stages ) document the observations of the mother as follows pulse rate – every 30 minutes blood pressure and temperature – every 4hrs Reproductive Health Module

64. Monitoring the mother during the third stage of labour Reproductive Health Module

65. Use the chart on the reverse side of the partogram to document the third stage Reproductive Health Module

66. Restless or drowsy? Alert & oriented? Respiratory rate Pulse rate Systolic Blood pressure details of the delivery Diastolic Blood pressure Reproductive Health Module

67. Urine output Consistency of the uterus Level of fundus Bleeding PV PV & PR findings if done Bladder dilation Neonatal condition Reproductive Health Module

68. Monitor & document maternal pulse at 15 min intervals, & SBP, DBP and r espiratory r ate at 30 min intervals . Palpate uterus for tone and level of fundus and document at 15 min intervals. High risk (PIH, cardiac diseases, PPH) mothers may need more frequent monitoring. M ark the level of fundus on the mother’s abdomen with a marker pen, any degree of rising of the level needs urgent attention Reproductive Health Module

69. Visual estimation of blood loss should be recorded Examine for a distended bladder & monitor urine output hourly if the mother is catheterized Vaginal and PR examination may be necessary depending on the clinical situation Reproductive Health Module

70. Inform MO/Senior MO if any parameter is recorded in one dark grey box or in two or more light grey boxes Close observation needed if any parameter is recorded in a light grey box If the observations are recorded only in the white boxes usual frequency of observation could be continued Reproductive Health Module

71. Thank You ! Reproductive Health Module