Normal Labour and partograph.pptx for ho

Normal Labour and partograph

1. Normal Labour and partograph

2. Normal Labour • WHO defines normal labour as "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"¹

3. Criteria for normal labour Labour is considered to be Normal when it meets the following criteria: Spontaneous expulsion Single, Full term i.e mature fetus (37 completed weeks - 42 weeks) Through vagina Presented by vertex Within a reasonable time (not less then 3 hours or more then 18 hours) Without aid (episiotomy or oxytocin) Without complications to the mother or the fetus .

4. ABNORMAL LABOUR (DYSTOCIA) "Any deviation from the definition of normal labour is called abnormal labour." "Labour in case with presentation other than vertex or having some complications even with vertex presentation affecting the course of labour or modifyng the nature of termination or adversely affecting the maternal/ fetal prognosis is called abnormal labour."

5. CAUSES OF ONSET OF LABOUR ➤ Uterine distension ➤ Stretching effect on the myomatrium ➤ Fetoplacental contribution ➤ Oestrogen ➤ Progesterone ➤ Prostaglandins ➤ Oxytocin and myometrial oxytocin receptors ➤ Neurological factor

6. Uterine distension Stretching effect on the myometrium by the growing fetus and liquor amnii Uterine stretch increases gap junction proteins, receptors for oxytocin and specific contraction associated proteins . Fetoplacental contribution Activation of fetal hypothalamic pitutary adrenal axis prior to onset of labour -> Increased CRH ( Corticotropin -releasing hormone) -> Increased release of ACTH (adrenocorticotropic hormone) -> fetal adrenals -> Increased cortisol secretion -> Accelarated production of oestrogen and prostaglandins from the plasenta

7. Oestrogen Increases release of oxytocin from maternal pituitary. Promotes the synthesis of myometrial receptors for oxytocin, prostaglandins and increase in gap junction in myometrial cells. Accelerated lysosomal disinteration in the decidual and amnion cells resulting the increased prostaglandin synthesis . Stimulates the myometrial contractile protein- actomyosin through cAMP (cyclic adenosinemonophosphate . Increases the excitability of the myometrial cell membranes.

8. Progesterone Increased fetal production of dehydro - epiandrosterone sulfate (DHES-S) and cortisol inhibits the conversion of fetal pregnenolone to progesterone. Progesterone levels therefore fall before labour. It is the alteration in the estrogen : progesterone ratio rather than the fall in the absolute concentration of progesterone, which is linked with prostaglandin.

9. Prostaglandins Prostaglandins are the important factors which initiate and maintain labour. The major sites of synthesis of prostaglandins are- amnion, chorion, decidual cells and myometrium. Syntheses is triggered by- rise in oestrogen level, glucocorticoids, mechanical stretching in late pregnancy, increase in cytokines, infection, vaginal examination , rupture of the membranes. Prostaglandins enhances gap junction formation.

10. Oxytocin and myometrial oxytocin receptors Large number of oxytocin receptors are present in the lower segment and cervix. Receptor number increases during pregnancy reaching maximum during labour. Receptor sensivity increases during labour . Oxytocin stimulate synthesis and release of PGs from amnion and decidua. Vaginal examination and amniotomy cause rise in maternal plasma oxytocin level. Fetal plasma oxytocin level is found increased during spontaneous labour compared to that of mother. Its role in human labour is not yet established.

11. Stages of Labour • First - onset of labour to full dilation • Second - full dilatation to delivery of baby • Third - delivery of baby to delivery of placenta • Fourth - first hour after delivery of the placenta

12. First stage of Labour • Further divided into : Latent phase Active phase Latent phase A prodromal phase of labour, characterized by at least 1 uterine contraction in 10 minutes, and cervical dilatation of less than 4cm. Active Phase from 4cm dilatation to full cervical dilatation

13. Second stage of labour Duration can be up to 2 hours Further divided into Phase 1 (Passive phase) Phase 2 (Active phase) Phase 1 Begins at full dilatation and ends with the urge to bear down. Initial lull in uterine activity Presenting part descends the pelvic floor Phase 2 From start of maternal effort to delivery of the baby Contractions longer, stronger and expulsive Pressure on pelvic floor causes an involuntary urge to bear down .

14. Third stage of Labour 2 Phases Separation phase Separation of the placenta from the wall of the uterus into the lower uterine segment and/or the vagina Expulsion phase Actual expulsion of the placenta

15. cont …….. stages onset end duration First stage Onset of true labour pains Full cervical dilatation Primi ; 12-16 hrs Multi;6-8 hrs Second stage Full cervical dilatation Delivery of the fetus Primi;1-2 hrs Multi;0.5 hr Third stage After delivery of the baby Complete expulsion of placenta and membranes Up to 30 minutes

16. Complications of labour FIRST STAGE Cord prolapse Fetal distress Maternal dehydration/exhaustion Poor progress in labour Obstructed labour Ruptured uterus SECOND STAGE Perineal lacerations Fetal distress Shoulder dystocia THIRD STAGE PPH Retained placenta

17. True labor vs. False labor True labor pain False labor pain Regular Irregular Increase progressively not Lower abdomen & back Lower abdomen Dilatation & effacement of cervix No effect on cervix Not relived by sedatives and antispasmodics Relieved

18. Mechanism of labour Also known as the cardinal movements of labour. Refers to the series of position and attitude, which the fetus undergoes during its passage through the birth canal. • The cardinal movements with vertex presentation are engagement, flexion, descent, internal rotation, extension, restitution, external rotation and expulsion

19. Descent : necessary for the successful completion of passage thru the birth canal Engagement : descent of the BPD below the plane of pelvic inlet. Flexion : allows for the smaller diameters of the fetal head to present to the maternal pelvis. Internal rotation : optimal diameters present to the bony pelvis Extension : to accommodate the upward curve of the birth canal Restitution External rotation : head rotates to face forwards relative to the shoulders. Expulsion

20. partograph A partograph , also known as a partogram, is a paper form used to record key labor data over time. It's a common tool for monitoring labor progress The partograph is the graphic recording of the progress of labour and the salient condition of the mother and the fetus . It serves as an “early warning system” and assists in early decision to transfer, augmentation and termination of labor.

21. Advantages of partograph Prevention of prolonged labor Avoids unnecessary use of augmentation Hand over of patients - More precise and fluent - At a glance appreciation of preceding hours of labor 22

22. Cont …… Pictorial display of events of labor - Clarifies recordings - Avoids lengthy written notes - Facilitates recognition of any omissions - Saves time → Companionship Considerable educational value - All interrelated variables of labor can be seen on a single paper Low cost, feasible Improved out come of labor →↑Credibility of formal health sector 23

23. Partogram - Disadvantages Assumes that all women progress at same rate – May influence intervention rate. Clinical findings have subjective variations. Lack o f knowledge. Non availability of printed partographs . Duplication of recording.

24. Partogram - History Emanuel Friedman's Partogram - 1954 Based on observations of cervical dilatation and fetal station against time elapsed in hours from onset of labor . The time of onset of labor 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 .

25. Cont ……. Philpott and Castle - 1972 •Introduced the concept of “ALERT” & “ ACTION” lines. •ALERT LINE – represent the mean rate of s lowest progress of labor ( 1c m/h r ) starting at zero time i.e. time of admission. •ACTION LINE – drawn 4 hrs. to the right of the alert line and parallel to it. If the progress crossed the alert line, appropriate action should be taken within 4 hrs . •Normal labor is plotted to the left alert line.

26. The WHO partograph Safe motherhood conference in 1987 concluded with “a call to action” This call to action demands that the health workers involved in the care of mothers and children take positive action now to reduce maternal mortality and morbidity.

27. cont...........

28. The Principles of WHO partograph The active phase of labour commences at 3cm cervical dilatation. The latent phase of labour should not last longer than 8 hours. During active labour , the rate of cervical dilatation should not be slower than 1cm/hr. A lag time of 4 hours between a slowing of labour and the need for intervention is unlikely to compromise the fetus or mother and avoids unnecessary intervention. Vaginal examinations should be performed as infrequently as is compatible with safe practice (once in 4 hrs ) Partograph with preset lines.

29. Modified WHO partograph The WHO partograph has been modified to make it simpler and easier to use(2001) The latent phase has been removed and plotting begins in the active phase when the cervix is 4 cm dilated

30. Component of the Partogram

31. Part I : Patient identification Name , Gravida, Parity Hospital number Date and time of admission Time of ruptured membranes.

32. Part II: fetal condition Fetal Heart rate: Record every 30 minutes Every 15 minutes in cases of fetal bradycardia or tachycardia Baseline fetal heart rate is 120-160 beats per minute. The amniotic fluid: record the colour at every vaginal examination I: membranes intact C: membranes ruptured, clear fluid M: meconium-stained fluid B: blood-stained fluid

33. Moulding : Is the overriding of the skull bones when the fetal head passes through the birth canal. An important indication of how adequately the pelvis can accommodate the fetal head. Degrees: Zero: bones apart 1+: bones touching 2+: bones overlap, reducible 3+: overlap, irreducible

34. PART III . PROGRESS OF LABOUR Rate of cervical dilatation of the cervix ( cervicograph ) Rate of descent of the presenting part. CERVICOGRAPH is divided into the latent and active phase. Modified WHO partograph has only the active phase Assess cervical dilatation every 4 hours 2 hourly if oxytocin augmentation is ongoing. Cervical dilatation marked with an X

35. Cervicogram Used between cervical dilatation of 4cm – 10cm. Cervix dilates at the rate of 1cm/hour Has the alert and action lines

36. cont …… Alert line An alert line is a visual representation of a cervical os dilatation rate of 1 cm/hour labor progress sustained throughout the active phase It is the slowest rate of active phase labor progress for normal labor outcome Action Line Drawn 4 hours to the right of the alert line (WHO Partograph) The critical point at which specific management decisions must be reducible

37. Descent The number of fifths of fetal head palpated per abdomen. Plotted on the same graph as the cervical dilatation. Marked with an O or a w

38. Cont ……. The progress of descent can also be estimated by measuring the station of the fetal head on VE. Station of fetal head Corresponding mark on the partograph –4 or –3 5 –2 or –1 4 3 +1 2 +2 1 +3

39. Uterine contractions Charted every 30 minutes. Palpate number of contractions in 10 minutes and the duration in seconds.

40. part IV: MATERNAL CONDITION Pulse Every 30 minutes Mark with a dot. (.) Blood pressure Every 4 hours Mark with arrows Temperature Every 2-4 hours Urinalysis Every 2-4 hours; for protein, ketones, glucose or blood Measure volume

41. Oxytocin : amount and number of drops/ minute every 30 minutes Other drugs and IV fluids are also charted on the partograph

42. cont.......

43. THE END