ACTIVE Mx OF LABOUR
Arnold wekesa
MED/20/11
NORMAL LABOUR
• DEF: sequence of regular painful uterine contractions that results in
progressive effacement and dilatation of the cervix and voluntary
bearing-down efforts leading to the expulsion per vagina of the
products of conception (i.e. the fetus, membranes, umbilical cord,
and placenta) at term.
• Cervical dilatation in the absence of uterine contraction = cervical
insufficiency.
• False labor: Contractions (irregular), no cervical changes, no progress
of the cervix, do not generate much uterine pressure.
STAGES OF LABOUR
• FIRST STAGE
- (cervical dilatation and effacement)
• SECOND STAGE
- (expulsion of fetus)
• THIRD STAGE
- (expulsion of placenta)
• FOURTH STAGE???
- (1 Hr after delivery of placenta)
First stage of Labour
• Begins with regular uterine contractions and ends with complete
cervical dilatation at 10 cm.
• Duration: primipara (6-18 hours) multiparous (2-10 hours)
• Lower limit of normal for the rate of cervical dilatation during the
active phase is 1.2 cm per hour in first pregnancies and 1.5 cm per
hour in subsequent pregnancies.
• divided into 2. Latent Phase and Active phase
• Latent phase- begins with mild, irregular uterine contractions that
soften and shorten the cervix.
• The contractions become progressively more rhythmic and stronger.
• Active phase of labor, which usually begins at about 3-4 cm of cervical
dilation. characterized by rapid cervical dilation and descent of the
presenting fetal part.
Second stage of Labour
• begins with complete cervical dilatation and ends with the delivery of
the fetus.
• Duration: primipara (30 minutes to 3 hours) Multiparous (5-30
minutes.)
• considered prolonged if; exceeds 2 hours in the absence of regional
anaesthesia or 3 hours if regional anesthesia is used for nulliparas.
• In multiparous women, considered prolonged if; exceeds 1 hour
without regional anesthesia or 2 hours with it.
Third Stage of Labour
• the time period between the delivery of the fetus and the delivery of
the placenta and fetal membranes.
• Duration: (0-30 minutes). Primipara and multiparous
• considered prolonged after 30 minutes
• Three classic signs indicate that the placenta has separated from the
uterus:
• The uterus contracts and rises,
• The cord suddenly lengthens, and
• A gush of blood occurs
Uterine
contractions sheer
the anchoring villi
from attachment at
the endometrial
decidual bed
Fourth Stage
• one hour after delivery of the placenta:
• Monitor vital signs and per vaginal bleeding closely
• Feeding the mother
• Breast feeding initiated within ½ - 1hr of delivery:
rooming in
Mechanism of Labour
• Engagement
• Descent
• Flexion
• Internal rotation
• Extension
• External rotation
• Expulsion
ACTIVE MANAGEMENT OF LABOUR
Aimed at reducing incidence of prolonged labor and was initially
developed for primigravidas.
Core principles:-early diagnosis following strict criteria.
2) charting rate of progression on a partogram
3)augmentation with amniotomy and oxytocin if
not dilating at the rate of 1cm per hour
4)personal and psychological support to the parturient.
5) early cord clamping and controlled cord traction with
uterotonic
The Partograph
• The partograph is a graphic recording of progress of labour and salient
conditions of the mother and the foetus.
• It consists of three components
• The foetal condition
• The progress of labour
• The maternal condition
It is used to
• Detect labour that is not progressing normally i.e. it is a
means of identifying the problem of prolonged labour;
• Indicate when augmentation of labour is appropriate;
• Recognize CPD long before labour becomes obstructed.
• It also increases the quality and regularity of all observations on the
foetus and the mother in labour, and aids early recognition of
problems with either.
• Hence the partograph serves as an “early warning sign” and assists in
early decision on transfer, augmentation and termination
of labour
Recorded things are among;
• Patient information: Fill out name, gravida, para, hospital number,
date and time of admission and time of ruptured membranes
• Fetal heart rate: Record every half hour
• Amniotic fluid: Record the colour of amniotic fluid at every vaginal
examination:
• I: membranes intact;
• C: membranes ruptured, clear fluid;
• M: meconium-stained fluid;
• B: blood-stained fluid.
Cont…
Moulding:
• 1: sutures apposed;
• 2: sutures overlapped but reducible;
• 3: sutures overlapped and not reducible
Cervical dilatation: Assessed at every vaginal examination and marked
with a cross (X). Begin plotting on the partograph at 4 cm
Cont…
• Alert line: A line starts at 4 cm of cervical dilatation to the point of
expected full dilatation at the rate of 1 cm per hour.
• Action line: Parallel and 4 hours to the right of the alert line.
• Descent assessed by abdominal palpation: Refers to the part of the
head (divided into 5 parts) palpable above the symphysis pubis;
recorded as a circle (O) at every vaginal examination. At 0/5, the
sinciput (S) is at the level of the symphysis pubis.
Cont…
Contractions: Chart every half hour; palpate the number of contractions in
10 minutes and their duration in seconds.
• Less than 20 seconds:
• Between 20 and 40 seconds:
• More than 40 seconds:
Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per
minute every 30 minutes when used.
Drugs given: Record any additional drugs given.
Pulse: Record every 30 minutes and mark with a dot (●).
Blood pressure: Record every 4 hours and mark with arrows.
Temperature: Record every 2 hours.
Protein, acetone and volume: Record every time urine is passed.
• Augmentation of labour : the use of oxytocin to increase the
frequency, intensity and duration of uterine contractions in a patient
whose labour has commenced spontaneously but is proceeding
slower than acceptable as per partograph.
Prolonged active phase
At/beyond the action line
The action line is 4 hours to the right of the alert line. If a woman’s labour reaches
this line, a decision must be made about the cause of the slow progress, and
appropriate action must be taken.
1. If POWER is inadequate, start oxytocin augmentation by intravenous
infusion.
2. If oxytocin augmentation gives strong contractions (as defined above)
monitor progress by cervical exam after 2 hours.
3. If oxytocin does not give good contractions (as defined above) monitor by
cervical exam after 4hours and consider amniotomy if there is no change.
4. If you tried to augment with oxytocin and amniotomy and there is still no
progress 2 hours after amniotomy then proceed to cesarean delivery.
Monitor fetal heart at least every half-hour during oxytocin augmentation
• 5 units of oxytocin is diluted in 500ml of Normal Saline and infused starting
at 4 drops per minute and escalated by 4 drops per min every 30 minutes.
The dose is escalated until 3 contractions in 10 minutes, each lasting 40
seconds or more, are achieved and maintained at that rate. If there are not
3 contractions in 10minutes at 60 drops per minute, then finish the
solution at that rate. Then start a new bottle with 10 units of oxytocin in
500mls and start infusing at 30 drops per min and escalate by 4 drops
every 30 minutes as before, to a maximum dose of 40 drops per minute.
• If hyperstimulation (>6 contractions per 10 minutes lasting 40 seconds or
more) occurs, stop infusion and administer Salbutamol.
Active management of third stage
at MTRH.
• Immediately after delivery of the infant the provider should palpate
the uterus to verify that there is not an undiagnosed and undelivered
twin.
• After verification that delivery is complete give 10 units of oxytocin in
500ml of Normal Saline IV or 10 units of oxytocin IM this will take
effect in 2-3 minutes.
• Massage the uterine fundus externally to encourage placental
separation.
• Use gentle downward cord traction to deliver the placenta while
applying supra-pubic pressure to prevent uterine eversion.
• If the placenta is not delivered in 10 minutes, place a foley catheter to
empty the bladder.
• If the placenta is not delivered within 30 minutes of continuous cord
traction, ensure IV access, check hemoglobin, and perform a manual
extraction of the placenta and give one dose of prophylactic ceftriaxone.
• Examine the placenta and membranes after removal to ensure that is it
complete.
• Empty the bladder to promote uterine tone
• If the blood loss is greater than 500ml at any time then act according to
the PPH protocol
Active Management of Third Stage
Palpate uterus to ensure no twin
Administer 10 units of oxytocin IM OR 20 units
in 1L Normal Saline
Apply gentle continous cord traction
If placenta is not delivered in
10 minutes ensure bladder is
empty
If placenta is not
delivered in 30
minutes perform
manual extraction and
give
1gm of ceftriaxone
Examine the
placenta to
ensure that it is
complete.
If incomplete
call
consultant
and move to
OR
Care of the new born infant:
• Clearance of the new passages.
• Determine the Apgar score at 1 and at 5 minutes
• Care of the umbilical cord stump
• General assessment of the infant to exclude any congenital
anomalies.
• Identification of weight, estimate the gestational age, dress it and
put a mask to identify it.
• Protect the baby against cold.
• THANK YOU