Partograms and assessment of progress in labour
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Partograms and assessment of progress in labour. Clare Tower MBChB PhD MRCOG Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer St Mary’s Hospital, Manchester. Overview. Definition of labour Normal labour

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Partograms and assessment of progress in labour

Clare Tower MBChB PhD MRCOG

Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer

St Mary’s Hospital, Manchester


Overview
Overview

  • Definition of labour

  • Normal labour

  • Diagnosis and assessment

  • Partograms

  • Abnormal labour

  • Cardiotocographs


Definition of labour
Definition of labour

  • Regular painful contractions resulting in cervical dilatation

  • 3 stages

    • First

    • Second

    • Third


Stages of labour
Stages of labour

  • First Stage

    • Up to fully dilated

    • Two phases

  • Second Stage

    • Full dilatation until

      delivery of the baby

  • Third stage

    • Delivery of the placenta


First stage of labour

Latent phase

Slow

Contractions irregular

Cervix:

shortens (effaces)

Softens

Moves

Dilates up to 3-4 cm

First Stage of labour



First stage of labour 2

Active phase

Regular painful contractions

Progressive cervical dilatation greater than 4 cm

First Stage of labour (2)


Progress of normal labour
Progress of normal labour

  • 5 Stages:

  • Descent

    • OT position

    • Widest part of head

    • Widest diam pelvis

  • Flexion

    • Stays OT

    • Chin to chest


Progress of normal labour 2
Progress of normal labour (2)

  • Internal rotation

    • At pelvic floor

    • Turns to OA

  • Extension

    • Crowning

    • Facilitated by sacral curve

  • External rotation

    • Restitution

    • Shoulders



Assessments in labour
Assessments in labour

  • The partogram

  • Labour record

  • Useful overview if completed properly

  • Can be used to aid diagnosis in abnormal labours

  • Visual representation of progress


Clinical info

Fetal HR

Liquor

Dilation and descent

Contractions Strength and timing

Drugs

Maternal Obs

IV fluids Urinalysis


Assessment
Assessment

  • History and review notes (handhelds)

  • Physical observations: temp, pulse, BP, urinalysis

  • Assess contractions: length, strength, frequency


Assessment1
Assessment

  • Abdominal palpation:

    • fundal height

    • lie

    • position

    • presentation

    • Station- relation to ischial spines

  • Vaginal loss

    • Show

    • Liquor

    • Blood loss


Assessment2
Assessment

  • Assessment of pain – need for pain relief

  • Fetal heart rate

    • Pinard or doppler

    • Listen for one minute after each contraction

    • Differentiate from maternal

    • Normal rate: 110-160

  • Vaginal examination

    • If appears to be in labour

    • With consent


Pain relief
Pain relief

  • Gas and air

    • 50/50 mix of Nitrous oxide (N20) and oxygen

  • TENS

    • Transcutaneous electrical nerve stimulation

  • Opiates

    • Pethidine or diamorphine

  • Epidural

    • Most effective

    • Local anaesthetic + opiate mix



Length of second stage
Length of second stage

  • Full dilatation until delivery

  • Can allow a ‘passive’ second stage for the head to descend

  • Epidurals

  • Total second stage less than 4 hours (NICE)

  • Pushing limited to 30 mins (multip) to 60mins (primip)


Abnormal patterns of labour
Abnormal patterns of labour

  • Partogram can be used to identify abnormal progress in labour

  • ‘3Ps’ – passenger, passages, powers

  • Deep transverse arrest

  • Primary dysfunctional labour


Obstructed labour
Obstructed labour

Assessment:

Powers

Passenger

Passages



Cardiotocograph ctg
Cardiotocograph CTG

  • Cardio = fetal heart rate

  • Toco = uterine activity:

  • Hence 2 monitors –

    • Abdominal pressure transducer

    • Doppler for fetal heart rate

  • Used to indicate fetal hypoxia

    • Poor!! – no reduction in the rate of intrapartum hypoxic injury/ Cerebral palsy since introduction in the 1980s

    • Increases rates of intervention

    • Even with the worse trace – 60% will be normoxic babies


Normal CTG

Fetal heart rate

Toco = uterine activity


Assessment of a ctg
Assessment of a CTG

  • DR C BRaVADO

  • DR = define risk

  • C= contractions

    • Timing and frequency

    • CTG cannot indicate strength

  • BRa = baseline rate

    • Normal 110-160

    • beware changes in rate

    • Fetal heart increases in the presence of maternal tachycardia and increased temperature

    • Also increases with hypoxia and sepsis


Dr c bravado
DR C BRaVADO

  • V= Variability

    • Band width

    • Should be more than 5bpm

    • If reduced can indicate fetal sleep/ maternal opiate use

  • A= Accelerations

    • Increase in baseline of more than 15bpm for more than 15 seconds


Dr c bravado1
DR C BRaVADO

  • D = Decelerations

    • = drops in fetal heart of more than 15bpm, lasting got more than 15 seconds

    • Time with contractions

    • Early – rare and benign

    • Late – pathological and indicate hypoxia

    • Variable – vary in timing and in pattern. Commonest and occur with cord compression

  • O = Overall

    • Make overall assessment taking into account all aspects


Variability = 20 bpm

Baseline rate

accelerations

Contractions

Irregular 1-2:10

Normal CTG

No decelerations


Baseline rate = 170-180

Variability = 5

Late decelerations

Abnormal CTG

Contractions 4:10

No accelerations




Instrumental delivery

Indications:

Failure to progress

Abnormal CTG

Risks

Maternal

Vaginal trauma

Perineal trauma

Bleeding

Fetal

Bruising/ trauma

Shoulder dystocia

Instrumental Delivery


Caesarean section
Caesarean Section

  • Elective - planned

  • Scheduled – maternal and fetal compromise not immediately life threatening

    • Deliver within 75 min

    • Audit of practice

  • Emergency: immediately life threatening

    • Deliver within 30 mins


Caesarean section1

Risks:

Maternal

Bleeding

Thrombosis

Bowel/ bladder damage

Infection

Anaesthesia

Hysterectomy

Next pregnancy

Fetal

lacerations 1-2%

TTN (transient tachyapnoea of the new born)

Indications

Failure to progress/ abnormal CTG

Caesarean Section



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