labour management

1. LABOUR MANAGEMENT

2. GOALS
1. To get correct diagnosis of labour
2. To learn regarding intrapartum management
3. To be able to identify abnormal labour and
manage accordingly

3. CORRECT DIAGNOSIS OF LABOUR
 Contraction occur at regular interval
 Interval gradually shortens
 Intensity of pain gradually increase
 Duration of contraction increase
 There is progressive cervical effacement and dilatation
 Progress of labour not stopped by sedation

4. WHY IMPORTANT??
 Proper monitoring
 Prevent unnecessary intervention
 ARM
 Wrong diagnosis of prolonged latent phase
 Admission
SALSO 2015

5. “FALSE” LABOUR !!
 Uterine contractions impalpable/ infrequent
 Misdiagnosis unnecessary induction/ augmentation
 higher risk of failure with an increased risk of
Caesarean section & chrioamnionitis

6. DEFINITION
 1st Stage:
 Start of labour  Full dilatation of cervix
 2nd Stage:
 Full dilatation  delivery of baby
 3rd Stage:
 Birth of baby  delivery of placenta

7. LATENT PHASE ACTIVE PHASE
1ST STAGE 2ND STAGE 3RD STAGE

9. POINTS TO OBSERVE FOR…
 Active phase: On or at the left of an alert line
 2nd Stage: Need proper assessment of the maternal
expulsion & descend of fetus
 3rd Stage : Retained placenta if not delivered by 30
minutes

10. LABOUR: PRINCIPLES OF MANAGEMENT
1. Initial assessment
2. Diagnosis and intervention of abnormal labour
3. Close monitoring of fetal and maternal condition
4. Adequate pain relief
5. Adequate hydration
6. Emotional support/ supportive companion

11. INITIAL ASSESSMENT
 Define risk
 Degree of monitoring needed
 Level of staff to manage the patient
• Depends on maternal coding and antenatal
risk factors
• Don’t forget to monitor vital signs

12. OBSERVATIONS OF MOTHER
*IF ANY OF THE FOLLOWING ARE OBSERVED, NEED IMMEDIATE ATTENTION
 Blood pressure (BP)- SBP > 140 and DBP > 90 mmHg in non
hypertensive patient
 Pulse rate (PR)- > 120 bpm on 2 occasions 30 mins apart
 Temperature (T)- > 38 degree celcius
 Proteinuria in a non hypertensive patient
 Any fresh vaginal bleeding
 Rupture of membranes more than 24 hours
 Presence of significant meconium
 Pain that differs from normal contraction (TRO rupture uterus)

13. OBSERVATIONS OF FETUS
*IF ANY OF THE FOLLOWING ARE OBSERVED, NEED IMMEDIATE
ATTTENTION
 Any abnormal presentation, including cord presentation
 Any abnormal lie
 Floating head per abdomen
 Suspected anhydramnions or polyhydramnions
 Abnormal fetal heart rate

14. PARTOGRAPH
 Diagrammatic representation of the progress of labour
 “Story of a patient in labour”
 Main components:
 Progress of labour
 Maternal condition
 Fetal condition
 Drugs given

16. MONITORING ON PARTOGRAM
 Maternal vital signs- BP, PR, T 4hly (unless high risk)
 4hly urine ketone
 Monitor contraction (TCM) every 1/2hly
 Descend of fetal head
 Vaginal examination (VE) every 4hly- progress of cervical
dilatation, degree of moulding & liqour colour
 Fetal heart rate monitoring

17. PARTOGRAPH
 PARTOGRAM X 2 PAGES
= PERINATAL
MORTALITY
 PARTOGRAM X 3 PAGES
= MATERNAL
MORTALITY

18. PARTOGRAPH
Patient came in active phase of labour  normal/ good
progress

19. PARTOGRAPH
Patient came in latent phase  normal progress

20. PARTOGRAPH
Patient came in latent phase normal progress

21. PARTOGRAPH
Patient came in latent phase  normal/good progress

22. ABNORMAL PARTOGRAPH (POOR PROGRESS)
 Latent phase > 8 hours
 Cervical dilatation to the right of alert line
 Cervical dilatation at or beyond action line

23. PARTOGRAPH
Dilatation < 4
cm despite 8
hours of
regular
contraction
Patient with prolonged latent phase

24. NON PROGRESSIVE LABOUR:THE THREE P’S
1. Power
2. Passage
3. Passenger
* Position
* Size
* Attitude

25. 1. POWER
 Adequate contractions are needed for adequate
progress of labour
 Usually 3-4 in 10 min
 Usually 40-60s duration

26. PARTOGRAPH

27. PARTOGRAPH
Dilatation < 1cm/
hour in active
phase due to
ineffective uterine
contractions < 3:10
< 40sec
Patient came in active phase  Primary dysfunctional
labour

28. AUGMENTATION
 Oxytocin (Pitocin)
 Correct dose and titration
 To achieve “efficient “/”adequate” contraction.
 Prevent hyperstimulation
 Careful consideration in multipara and previous scar

29. HYPERSTIMULATION
 Prolonged contractions (> 2 mins)
 Frequent contractions (<1:2)
 Tetanic contractions (continuous)

30. 2. PASSAGE
 Clinical @ x-ray pelvimetry – not used in modern
obstetrics
 Adequacy of pelvis can only be ascertain through
labour and delivery
 Passage may be adequate but might not be for a big
baby!!

31. EVIDENCE OF OBSTRUCTED LABOUR
 Secondary arrest
 Large caput
 3rd degree moulding
 Poorly applied cervix to presenting part
 Odematous cervix
 Maternal/ fetal distress

32. SECONDARY ARREST
 Arrest of cervical dilatation and descent of presenting
part despite good uterine contraction
ABSOLUTE CPD RELATIVE CPD
BIG BABY/ SMALL PELVIS FETAL
MALPOSITION

33. PARTOGRAPH
Patient came in active phase  Secondary arrest

34. 3. PASSENGER
 Size of baby
 Congenital abnormalities e.g. hydrocephalus
 Malposition (e.g. OP), malpresentation (e.g. breech,
brow)

35. FHR MONITORING
 Pinard stethoscope or Daptone
 In latent phase: Intermittent auscultation
* Low risk : Hourly
* High risk : Every 15-30 min
: CTG
 In active phase: Intermittent auscultation
* Low risk: Every 30 min
* High risk: Every 15 min
CTG

36. FHR MONITORING
 During second stage: Intermittent auscultation
* Low risk : Every 15 min
* High risk: Every 5 min or after each
contraction/pushing
: CTG

37.  Cardiotocography
 Management of suspicious tracing is not to wait or
repeat the CTG until it become normal/reactive
 The stressor to the fetus is the contraction not the
degree of cervical dilatation
FHR MONITORING

38. FHR MONITORING
 If patient in labour (contracting)
FETAL HEART HEARD
!!! NOT ENOUGH
**palpate the maternal HR to differentiate between
maternal & fetus
SALSO 2015

39. ADEQUATE ANALGESIA
 Every patient have a right for good analgesia in labour
 “ TARIK NAFAS” is not an analgesia at all
 Breathing exrecises, immersion in water & massage may
reduce pain in latent phase of labour
 IM Pethidine 1-2mg/kg + Phenergan 0.5mg/kg 6 hourly
 Entonox inhalation (50% O2 and 50% Nitrous oxide) at
the start of contraction
 Continuous epidural analgesia

40. EPIDURAL ANALGESIA
 Available in SGH
 More effective pain relief than opiods
 Not associated with long term backache or paralysis
 Not associated with a longer 1st stage of labour or
increased caesarean section rate
 Associated with longer 2nd stage and increased chance
of instrumental delivery

41. HYDRATION
 Good hydration is important for satisfactory labour
progress
 Review hydration status regularly (Don’t just
concentrated on VE finding)
 Urine volume and urine ketones assessed
 Allow low residual diet / oral fluids in labour except
for high risk cases

42. CONTROLLING GASTRIC ACIDITY
 Either H2 – receptor antagonist or antacids should be
considered for women who
 receive opiods
 develop risk factors that make general anaesthetic
more likely

43. COMPANIONSHIP / DOULA
 Provides reassurance to patient
 Shown to:
 Reduce analgesia requirements
 Reduce Caesarean section & instrumental
 Improve vaginal delivery rates

44. PARTNER
 PARTNER ARE IMPORTANT, ESPECIALLY
SUPPORTIVE AND HELPFUL ONES

45. SECOND STAGE OF LABOUR…
 STILL NEED TO CLOSELY MONITOR
1. Maternal vital signs- BP, PR
2. Progress of pushing and descend of fetal head
3. CTG monitoring
** NEED ATTENTION if 2nd stage more than 1H in nulliparous and
1/2H in multiparous
** If contraction is INADEQUATE can consider to use oxytocin

46.  Intrapartum interventions to reduce perineal trauma
1. DO NOT perform perineal massage in the second stage
2. ’Hands on’ to guard the perineum & flexing baby’s head
3. DO NOT carry out routine episiotomy
4. If episiotomy needed, the recommended technique is
mediolateral episiotomy

47. DELAYED CORD CLAMPING
 Do not clamp the cord earlier than 1 min from the birth
of baby,unless resuscitation of newborn is needed
 Clamp the cord before 5 min in order to perform CCT

48. THIRD STAGE OF LABOUR
 Active management of 3rd stage
1. Usage of uterotonics
2. Delayed cord clamping and cutting (up till 5 minutes)
3. CCT after signs of placenta separation
 Monitoring during 3rd stage
1. Maternal vital signs
2. Degree of vaginal bleeding
** NEED ATTENTION if 3rd stage delayed more than 30
mins