NORMAL LABOUR; ACTIVE MANAGEMENT

OF LABOUR AND DELIVERY:

USE OF PARTOGRAPH

J.O.E
 OBJECTIVE
 AT THE END OF THIS SESSION
 THE STUDENT IS EXPECTED TO
UNDERSTAND THE CONCEPT OF LABOUR
 DEFINE PRECISELY THE TECHNICAL TERMS IN
LABOUR MANAGEMENT
 BE ABLE TO DIAGNOSE LABOUR
 BE ABLE TO EXPLAIN THE PROCESS OF
NORMAL LABOUR
 PLOT AND INTERPRET THE PARTOGRAPH

OUTLINE

 INTRODUCTION
 DEFINITION OF LABOUR
 CLASSIFICATION AND DEFINITION OF
TERMS
 PROCESS OF LABOUR
 STAGES OF LABOUR AND MANAGEMENT
 ANALGESIA IN LABOUR
 PARTOGRAPH
INTRODUCTION

 Labour is the process of parturition and it

follows the biblical injunction or curse in
the book of Genesis 3:16. The pain of
childbirth can however not be said to be a
deterrent to the parous experience women
have in view of the high total fertility rate
in Africa. (NGN nat average 5.3 U4.5 R5.8)
 Labour is characterized by uterine
contractions of at least 1 in 10 mins with
associated cervical effacement and
dilatation with subsequent expulsion of
the product of conceptus and the
placenta
 It is the climax of an event which started
about a month earlier
VAGINAL DELIVERY
 Best form of delivery
 Associated with less mortality and
morbidity
 Over 80% of deliveries
 A sign of strength in some cultures and
culturally acceptable
 faster fetomaternal bonding compared to
CS
prelabour phase.
 The uterus at the resting phase has a
pressure of about 5mmHg. Increases to
about 10mmHg in pregnancy -Braxton Hicks.
 This increases as the pregnancy continues
towards term when it becomes painful
 contraction increases in frequency and
intensity and radiates to the back and to
the thighs.
 This is also associated with an increase in
blood flow to the cervix and increased
prostaglandin actions. This in turn leads to
the softening of the glycosaminoglycan
Definition of terms

 FALSE LABOUR: Spontaneous onset of painful,

palpable , rhythmic uterine contractions with no
progressive cervical changes within
24hours of observation. It is therefore a
retrospective diagnosis. It can also be defined in
a more technical way as failure of progression
from latent phase into active phase in a
woman at term within a 24 hour period of
observation

 PRE TERM LABOUR; Spontaneous onset of

painful, palpable , rhythmic uterine contractions
with progressive cervical changes after 28weeks
 PRECIPITATE LABOUR. Spontaneous onset of
painful, palpable , rhythmic uterine contractions with
progressive cervical changes and expulsion of the
products of conceptus within 3 hours. This might mean
a defective cervical structure or too vigorous
contractile forces. It portends great danger for the
fetus as it can lead to tentorial tears; intracranial
haemorrhage and asphyxia while in the mother it
can lead to PPH and perineal injuries

 TRUE LABOUR. True labour is painful, rhythmic,

palpable contractions with increasing intensity ,
frequency of at least (1 in 10mins ) and it is associated
with effacement and progressive cervical dilatation
 NORMAL LABOUR. This is a diagnosis made
in retrospect, it is spontaneous onset of
painful, rhythmic, palpable contractions
with increasing intensity , frequency of at
least (1 in 10mins ) and it is associated with
effacement and progressive cervical
dilatation with descent of the presenting
part and subsequent expulsion of the
placenta and the fetus without any
assistance apart from episiotomy in a
singleton fetus presenting cephalad.
 FIRST STAGE OF LABOUR. This is defined in
terms of cervical dilatation. This is from the zero
cervical dilatation to 10cm or full cervical dilatation
 SECOND STAGE. This is from the point of full
cervical dilatation to the delivery of the baby
 THIRD STAGE. The stage begins at the delivery of
the fetus up to the delivery of the placenta.
 FOURTH STAGE. This is not often mentioned by
most obstetrician though is the most critical period.
The definition is also not harmonized but generally
it is defined as the first 2 hours after delivery of the
fetus
 ACTIVE PHASE when the parturient is 4cm
dilated and 100% effaced in a woman in
labour. Some people however differentiate
into nullip as above and multip 50%
effacement and 3cm dilation since dilatation
precedes effacement in multip and
effacement precedes dilatation in nullip
 LATENT PHASE when the cervical
dilatation is less than 3cm in a parturient in
labour
COURSE OF LABOUR

 The activation of the process of labour is

inherent in the fetal brain
 Intact H-P-A is very crucial
Fetal brain

CORTISOL DHEAS
LUNG MATURATION ESTROGEN PRODUCTION

Increase Estrogen in
Fit for survival amniotic fluid activates
membranes, PG and labour
 The increased PGF2 and PGE activity
stimulate the activity of the uterine
muscles for the contraction to
commence. This leads to a transition
from the quiescent resting tone of
5mmHg to a palpable 10mmHg and
painful 15mmHg cascading to the
expulsive 75mmHg force.
 The uterine muscle has a unique ability of
contraction, retraction and relaxation.
 It is a power machine that serves to expel the fetus
as well as a haemostatic tool and this is dominant in
upper segment
 The lower segment is more passive .
 if the entire uterus, including the lower uterine
segment and cervix were to contract simultaneously
and with equal intensity, the net expulsive force will
be decreased. The upper segment contracts and
retracts to expel the fetus ; in response to this the
ripened lower uterine segment (LUS) and cervix
dilate and thereby form an expanded , thinned out
muscular and fibromuscular tube through which the
 When the ring is extremely thin as it
occurs in obstructed labour, the ring
is very prominent and known as a
pathological retraction ring of Bandl
(Bandl's ring). It may signify intending
rupture of the uterus
 PROCESS AND MECHANISM OF
LABOUR
 A process of adaptation or
accommodation of suitable portions of
the head to the varying segments of the
pelvis is required for the birth of the
fetus. The mechanism involved are
sequential and seamless without any
obvious demarcation. These are 1)
descent 2) Engagement 3) flexion 4)
internal rotation 5) external rotation 6)
restitution & 7) extension
STAGES OF LABOUR

 FIRST STAGE
 Latent phase. Last 8 hours max. >24hrs
false labour
 Active phase. Point of admission in AML.
4cm dilated and 100% effaced.
 A companion in labour is allowed Doula
 Nutrition in labour to prevent acidosis and
dehydration
 Analgesic to relieve the pain of labour
 Early amniotomy improves outcome
except where contraindicated like in
breech presentation, IUFD, HIV in
labour.
 Cervical dilatation occurs at a minimum of
1cm per hour (1.2-1.4cm hour in multip and
1-1.2 in nullip). It is therefore expected that
within 6-8 hours the first stage of labour
should have been completed. Prolonged
active phase is when the phase is not
completed within 12 hours.
Active management of labour (AML)

 Is strategic approach to the

management of labour already
established in the active phase aimed at
the prevention of prolonged labour. It is
based on the anticipation of normal
progress of the cervical os dilatation of
1cm per hour as the basis for the safe
delivery of the mother with no
complication to both mother and child.
Basis of Practice of AML
 Active phase is the more important aspect of first
stage of labour
 normal progress of the cervical os dilatation of 1cm
per hour as the basis for the safe delivery
 uterine inertia and not CPD is commonly the
cause of failure of cervical dilatation as
expected
 uterine inertia responds well to oxytocin
augmentation both for cervical dilatation and descent
of the presenting part in second stage of labour.
 Artificial rupture of membranes in the active phase
facilitates cervical Os dilatation at 1cm per hour
 Companion in labour and assurance that active phase
will not exceed 12 hours enhance performance in
THE PARTOGRAPH

 Partogram is the instrument for the monitoring of the

progress of labour.
 Partograph is a graphic record of the events of the first
stage of labour. It is an instrument that has evolved over
years .
 Friedman hypothesis of 1954
 to Hendricks in the 60s, says no descent
 Philport of 1971s
 WHO plots of 1989 (composite),
 2000(modified)
 2006(simplified). No head descent
 The composite is the baseline for modern modifications
and the modified is used in the AML.
Types of partograph

composite modified
Types of partograph

A plain adapted model

 . The graphic nature

made it to be easy
to recognize changes
in feto-maternal vital
signs and the graph
serves as a easy tool
for teaching and for
handing over
between shifts.
 COMPONENTS OF THE
PARTOGRAPH

 Demographic
 Fetal components
 Cervicogram and descent
 Contraction pattern and oxytocin use
compartment
 Drugs used
 Maternal vital signs and
 Urine production and analysis
SECOND STAGE OF LABOUR
 signals the process of "landing on the
tarmac" by the baby
 Expected to be completed in 1 hour.
 However an extra hour can be allowed
for a nullip if the presenting part was
high at full cervical dilatation
 epidural anaesthesia blunts the effect
of the expulsive force (involuntary
contraction) and may therefore necessitate
the use of instrumental deliveries
2nd Stage
 Delivery of the fetus is best conducted
where she had her labour.
 Modes of delivery can be:
 On all fours;
 Squatting position
 In the bath as previously planned
during the antenatal period.
 Routine resuscitation of the baby is not
done and ability to do the APGAR scoring is
very important
THIRD STAGE OF LABOUR

 This is done actively (Active

management of the third stage of labour
AMTSL)
 Separation of the placenta occurs from
the sudden diminution of uterine volume
following the delivery of the baby. This
leads to shearing off of the placental
from the uterine attachment along the
decidua basalis
 Completed within 10mins and max
30minutes
Passive management of third stage

 Signs of placental separation awaited

 lengthening of the cord;
 a gush of blood
 uterine fundal elevation and globular
outlook
AMTSL
 Parenteral oxytocic at the delivery of
the anterior shoulder
 Delayed cord clamping (1-3mins)
 Controlled cord traction using the
Brandt-Andrew method
 Uterine massage to ensure contraction
oxytocics
 Oxytocin 10i.u
 Syntocinon 10i.u
 Ergometrine 0.5mg
 Syntometrine (0.5mg +5i.u)
 Methyl ergometrine(methergine)
 Misoprostol 200-600micrograms
 Carbetocin 100ug. Long half live and
sustained contraction
The fourth stage of labour
 where the obstetricians nightmare
(Maternal mortality) occur due to Post
partum haemorrhage.
 It is the first 1-2 hours after delivery.
The episiurrhaphy is done and the
woman is kept under observation before
being transferred to the lying in ward.
 There is less emphasis on this stage
THE DETERMINANTS OF A SUCCESSFUL
VAGINAL DELIVERY

 THE POWER
 THE PASSAGE
 THE PASSENGER
Power
 Contractile force from 5mmHg to 60-
75mmHg
 Minimum of 3 in 10minutes lasting 45s
 Inadequate power or inertia can be
corrected with oxytocin infusion
 Uterine masses like fibroid; full bladder;
and dehydration can reduce the rate of
contractions
The passage
 Gynaecoid pelvis is most suitable for delivery.
 The android pelvis: Deep transverse arrest
 platypelloid predisposes to Cephalopelvic
disproportion due to inlet abnormality
 anthropoid pelvis will predispose to persistent
occcipitoposterior position.
 Pelvic masses like uterine fibroid can slow down
the progress in labour and obstruct the passage.
Tumours of the cervix can also change the
course of labour. Adequacy of the pelvis can be
assessed by the clinical, X-ray or C-T pelvimetry
Passage abnormalities
 Naegeles pelvis
 Ricketts
 Poliomyelitis
 Contracted pelvis
 Pelvic fractures
The passenger
 For normal delivery the baby should:
 be in the longitudinal lie
 cephalic presentation
 flexion attitude,
 presenting vertex
 of average weight. 3.0-3.5kg
 Babies in abnormal lie have poor
prognosis.
GRACIA