Explain regarding labour and partogram

1. Labour and partogram
By Dr Vasanthan Saigaran

2. • Def-physiologic process during which the products
of conception (ie, the fetus, membranes, umbilical
cord, and placenta) are expelled outside of the
uterus.
• Sign and symptoms of labour
– Regular painful uterine contraction
– Show ( blood-stained mucous discharge)
– Leaking liquor (ROM)
– Shortening and dilatation of cervix
• Three Stages of labour

3. Stages of Labour
• First stage – stage of cervical dilatation
– From onset of labour/ true labour until cervix is fully
effaced( 10 cm )
1. Latent phase- mild, irregular uterine contractions that
soften and shorten the cervix.
2. Active phase-begins at about 3-4 cm to 10 cm fully dilated
cervix and is characterized by rapid cervical dilation and
descent of the presenting fetal part
- Primi ( 12 hours)
- Multigravida (8 hours)

4. • First stage – stage of cervical dilatation
– From onset of labour/ true labour until cervix is
fully effaced( 10 cm )
1.Latent phase- mild, irregular uterine contractions
that soften and shorten the cervix.
2.Active phase-begins at about 3-4 cm to 10 cm
fully dilated cervix and is characterized by rapid
cervical dilation and descent of the presenting
fetal part
- Primi ( 12 hours)
- Multigravida (8 hours)

5. Mechanism of Labour
• Engagement
– The widest diameter of the
presenting part or
Biparietal (vertex) diameter
descent below the pelvic
brim
– Descent of fetal head into
pelvis usually described as
if the head is divided into
five segments
– Imaginary line joining the
ischial spine is station 0

7. • Descent and Flexion and internal rotation
– fetal vertex descents through the pelvis with
contraction
– Fetal head well- flexed
– Fetal head enters in the ocipitotransverse
then rotates to address anteroposterior
diameter of outlet

8. • Extension and delivery of head
– Upward resistance from the pelvic floor and
the downward forces from the uterine
contractions cause the occiput to extend and
rotate around the symphysis. This is followed
by the delivery of the fetus' head.

9. • Restitution, external rotation and delivery of
the shoulders
– Head restitutes to align itself naturally
perpendicular to shoulder
– shoulder enter pelvis in oblique position
– Anterior shoulder deliver assisted by lateral
flexion of the body
• Delivery of body
– Post shoulder deliver with opposite traction
upward

11. PARTOGRAM
• Process of labour
– Cervical dilatatiion
– Head level
– Contraction pattern
• Fetal condition
– Fetal heart rate
– Appearance of amniotic fluid
– Presence of moulding
– Presence of caput
• Maternal condition
– Pulse
– BP
– Temperature
– Urine volume and constituent

13. • The alert line is plotted to correspond with the onset
of the active phase of labor(dilation of the cervix to 4
centimeters).
– should expect dilation to continue at about the rate of 1
centimeter per hour.
• The action line is plotted 4 hours after the alert line. If
the woman’s labor is not following the expected
course after 4 hours, the plot of her labor will begin to
approach the action line, signaling the need to take
action.
• Interventions that may be appropriate when the
action line is crossed include the use of oxytocin to
augment labor, vacuum-assisted birth (if the cervix is
fully dilated),or cesarean section.

14. • FHR –
– Normal ( 120-160 bpm)
– Fetal bradycardia ( below 120 bpm) –
maternal asministered drugs eg; opiates or
fetal cardiac abnormalities eg; heart block and
fetal hypoxia
– Fetal tachycardia ( above 160 bpm ) –
maternal disease such as infection and
thyrotoxicosis, administered drug as atropine
and hydralazine, fetal prematurity, infection
and hypoxia

15. • Look for liquor
– Clear
– MSL indicate underlying fetal hypoxia
– Light MSL if CTG reactive, manage as normal
labour
– Thick MSL – LSCS if in early labour
• If advanced labour, consider instrumental delivery

16. Moulding
• Fetal scalp bones are not fused allow
separation or overlap during passage
through maternal pelvis
• Described as the extent of
overlapping of fetal skull bones
• To identify moulding, first palpate
the suture lines on the fetal head
– 0 Bones are separated and the
sutures can be felt easily.
– +1 Bones are just touching each
other.
– +2 Bones are overlapping but can be
separated easily with pressure by your
finger.
– +3 Bones are overlapping but cannot
be separated easily with pressure by
your finger

17. • Opening of cervix
measuring in
centimeters
Cervical dilatation

18. Management in 1st stage of labour
• Mother
– Half hourly BP/vital sign
– 4hrly temp, urine output, ketone or albumin
– effective analgesia
– Record progression of labour in partograph
• Fetus
– FHR
– CTG- hourly CTG for ( medical disorder, previous scar,
oligohdramnions, suspected fetal compromised, MSL

19. Management of 2 nd stage of
labour
• Should not encourage maternal bearing
down until fetal head descended to pelvic
floor
• Support perineum with pad during delivery
• Ensure fetal head is well flexed till delivery
• Give syntometrin at delivery of anterior
shoulder

20. Management of 3 rd stage of
labour
• Delivery placenta by CCT and check
completeness
• Make sure vital sign mother are stable and
uterus well contracted before

21. Abnormal labour
• Prolonged labour
• Obstructed labour

22. Prolonged labour
• Progress in labour dependend on 3 variables
• Powers(uterine efficiency)
– Inefficient uterine contraction a/w maternal age
– Also a/w CPD , uterine overdistension eg; twin and malposition
• Passenger(fetus)
– Size or macrosomia baby, malposition , malpresentation( brow,
shoulder,face. Breech)
• Passages
– Primary uterine dysfunction due to dispropotion, stenosis
ofvagina , stenosis or scarring of cervix, contracted bony pelvis,
pelvic tumor

23. Prolongation of labour
• Prolong latent phase
• Primary dysfunctional labour
• Secondary arrest
• Prolonged second stage of labour

24. Prolonged Latent phase
• Failure of thinning of lower segment, effacement of
dilatation of cervix despite several hours of painful
contractions
• 8 hours in primi and 4-6 hours in multipara
• Management
– Assess after 4-6 hrs
– If in labour and a/w CPD or malpresentation, LSCS is indicated
– In absent of complication, need reassurance , hydration,
nutrition and ambulation
– Best manage conservatively, in most instances, may develop
painful contraction within 24-48 hrs and deliver normally

25. Primary dysfunction labour
• Most common in first labour
• A slow progress during active phase of labour a/w inefficient
uterine contractions
• (delay in the early part of active phase ie 3-7 cm )often respond
well to augmentation
• Management
– TRO possible genuine CPD , large baby, malpresentation or small pelvis
– Ensure adequate Hydration and analgesia in labour
– ARM if MI
– Considered oxytocin augmentation
– LSCS when there is poor progress in cervical dilatation or descent of
presenting part or CTG show variable deceleration suggesting head
compression due to CPD

26. Secondary Arrest
• Normal progress of labour in initial active
phasebut prolongation of late first stage of
labour, arrest of cervical dilatation typically
after 7 cm
• Commonly a/w malposition and CPD
• Management
– Oxytocin augmentation if there is no CPD
– LSCS indicated If CPD is present

27. Prolonged 2nd stage of labour
• After full dilatation of cervix , the delivery is not effected within
an hour or less
• Management
– TRO possibility of CPD
– Hydration if weak contractions are a/w maternal dehydration or
ketosis
– Some more time allowed in these situtation provided mother
and fetus carefully monitored
– In absence of CPD, prev uterine scar or multiparity, controlled
oxytocin infusion may help if the contractions are not adequate
– Assisted vaginal delivery if labour progress and head descent
– LSCS if no descent especially if evidence of maternal exhaustion
or fetal distress

28. THANK YOU