Management of normal labour and partogram

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

 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

 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

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.

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).

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.

 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.

 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.

Initiation of Labour

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

Third Stage - delivery of the baby to delivery of the
placenta

Mechanism of Normal labour

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

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

 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

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.

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

 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:

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

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

 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 reliefReproductive Health Module

 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

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

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.

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

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)

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:

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

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

Period from complete delivery of the baby to the
complete delivery of the placenta and membranes
Third stage of labour

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

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

• 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:

 Delayed third stage is diagnosed if the placenta is
not delivered within 30 minutes of active
management
Delayed third stage

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

Maintaining the new
partogram

Partogram:
Is a graphic representation of the events of labour
All the observations made on the mother and the
fetus are plotted in one sheet
Helps in early recognition of abnormal labour
and fetal distress.

Time of Vaginal Examination
Information of the mother
• Name
• Age
• BHT number
• POG
• Gravidity
• Parity
• Blood group
• Date & Time
• Special problems
• Special instructions

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)

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 ⊙

Mother’s
observations
• Pulse rate
• Blood pressure
• Temperature
Actions takenReproductive Health Module

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)

When should the partogram be started?
If the frequency of uterine
contractions is 2 or more per 10
minutes
or
At induction of labour with
oxytocin or by amniotomyReproductive Health Module

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

example of a FHR recording
Commencement of the active phase of the second stage

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

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

Documentation of cervical dilatio
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

10
9
8
7
6
5
4
3
2
1
0
4 hours
Cervicaldilation
abdominaldescent
Abdominal descent

Descent of the fetal head
on abdominal palpation

 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

Maintaining the
partogram during the
second stage of labour

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

 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

Monitoring the mother during
the third stage of labour

Use the chart on the reverse side of the
partogram to document the third stage

Restless or drowsy?
Alert & oriented?
Respiratory rate
Pulse rate
Systolic Blood pressure
details of the delivery
Diastolic Blood pressure

Urine output
Consistency of the
uterus
Level of fundus
Bleeding PV
PV & PR findings if done
Bladder dilation
Neonatal condition

 Monitor & document maternal pulse at 15 min intervals, &
SBP, DBP and respiratory rate 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.
 Mark the level of fundus on the mother’s abdomen with a
marker pen, any degree of rising of the level needs urgent
attention

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

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

Thank You!Reproductive Health Module

Management of normal labour and partogram

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