introduction about normal labour and how to monitor by partogram.

1. BY
Dr. Sarah Mohamed Hamed Aboelsoud
Senior Registrar of obstetrics& gynecology
Damietta General Hospital

2. Definition:
is the process by which the fetus is delivered after
the 24th week of gestation. The onset of labour is
defined as the point when uterine contractions become
regular and cervical effacement and dilatation becomes
progressive.

3.  labour is characterized by:
1. Onset of uterine contractions, which increase in
frequency, duration, and strength over time.
2. Cervical effacement and dilatation.
3. Rupture of membranes with leakage of amniotic fluid.
4. Descent of the presenting part through the birth
canal and Birth of the baby.
5. Delivery of the placenta and membranes.

4.  Engagement and descent: the head enters the pelvis in the Occipi-
transverse position with flexion ↑ as it descends.
 Internal rotation to occipitoanterior: occurs at the level of the
ischial spines due to the forward and downward sloping of the levator
ani muscles.
 Crowning: the head extends, distending the perineum until it is
delivered.
 Restitution: the head rotates so that the occiput is in line with the
fetal spine.
 External rotation: the shoulders rotate when they reach the levator
muscles until the biacromial diameter is anteroposterior (the head
externally rotates by the same amount).
 Delivery of the anterior shoulder: occurs by lateral flexion of the
trunk posteriorly.
 Delivery of the posterior shoulder: occurs by lateral flexion of the
trunk anteriorly and the rest of the body follows.

5.  Myometrial Changes during phase 1 of labour:
1. The uterine smooth muscle must undergo a series of changes
to prepare for labor.
2. There is a striking increase in myometrial oxytocin receptors.
3. There are increased numbers and surface areas of myometrial
cell gap junction proteins such as connexin-43.
Together these changes result in increased uterine irritability
and responsiveness to uterotonins.
 Phase 2: The Process of Labor
Phase 2 is synonymous with active labor, that is, the uterine
contractions that bring about progressive cervical dilatation and
delivery.

6. The first stage is divided into a relatively flat latent phase and a rapidly
progressive active phase. In the active phase, there are three identifiable
component parts: an acceleration phase, a linear phase of maximum slope, and a
deceleration phase.

7. The 1st stage is divided into two phases:
• Latent phase: the period taken for the cervix to completely
efface and dilate up to 3cm.
• Active phase: from 3cm to full dilatation (10cm).

8.  There is <2cm dilatation in 4h (on a 4hr action line
partogram ( the plotted progress falls to the right).
 Slowing in progress in parous women.
( 2 Consideration should also be given to effacement of
cervix and descent of the head).
Some causes of poor progress in the 1st stage must be
excluded:
1. Inefficient uterine activity ( power —commonest cause).
2. Malpositions, malpresentation, or large baby ( passenger).
3. Inadequate pelvis ( passage ).
4. A combination of two or more of the above.

9. Assessment
1. Review the history.
2. Abdominal palpation, frequency, and duration of
contractions.
3. Review fetal condition; fetal heart rate and color/quantity of
amniotic fluid.
4. Review maternal condition including hydration and
analgesia .
5. Vaginal assessment; cervical effacement, dilatation, caput,
moulding, position, and station of the head.

10. Management
1. Amniotomy (artifical rupture of membranes (ARM)) and reassess
in 2h.
2. Amniotomy + oxytocin infusion and reassess in 2h: this should
always be considered in nulliparous women.
3. Lower segment CS (if there is fetal distress).
4. For multiparous women and those with a previous CS an
experienced obstetrician should review before starting oxytocin.
5. Monitoring in labour (recorded on the partogram):
-The FHR should be monitored every 15min (or continuously with a
CTG).
- The contractions should be assessed every 30min.
- Maternal pulse should be checked hourly.
- BP and temperature should be checked 4-hourly.
- VE should be offered every 4h to assess progress.
- Maternal urine is tested 4-hourly or when passed for ketones and
protein.

11. Objectives:
1. Record and assess the condition of the mother.
2. Record and assess the condition of the fetus.
3. Record and assess the progress of labour.

12. A. Recording the blood pressure, pulse and temperature
The maternal blood pressure, pulse and temperature
should be recorded on the partogram.
B. Recording the urinary data
Volume is recorded in ml.
Protein is recorded as 0 to 4+.
Ketones are recorded as 0 to 4+.

14.  The following two observations must be recorded on the partogram:
1. The baseline heart rate.
2.The presence or absence of decelerations.
If decelerations are present, you must record whether they are early or late
decelerations.
 Recording the liquor findings:
Three symbols are used:
I = Intact membranes, C = Clear liquor draining, M = Meconium-
stained liquor draining.
 How often should you record the liquor findings?
The recordings should be made at each vaginal examination.
Whenever a change in the liquor is noted, e.g. when the membranes
rupture or if the patient starts to drain meconium-stained liquor after
having had clear liquor before.

16. 1. Recording the cervical dilatation
Cervical dilatation is measured in cm and then recorded by
marking an ‘X’ on the partogram.
2. Recording the length of the cervix (effacement)
The length of the cervix is recorded by drawing a thick
vertical line on the same part of the chart that is used for the
cervical dilatation.
The length of the line drawn indicates the length of the
endocervical canal in cm. It is drawn on the chart whenever
the cervical dilatation is recorded.
3. Recording the amount of the head palpable above the
brim of the pelvis (descent and engagement)
The findings are recorded by marking an ‘O’ on the
partogram.

18. Recording the position of the fetal head
The position of the fetal head is recorded by marking the ‘O’ with fontanelles
and the sagittal suture. This is recorded at every vaginal examination.
Recording moulding of the fetal head
The degree of moulding (i.e. 0 to 3+) is also recorded on the partogram.
Recording the duration of contractions
The duration of contractions is also recorded on the partogram. The block is
stippled if the contractions last less than 20 seconds (i.e. weak contractions), the
block is striped if the contractions last between 20 and 40 seconds (i.e. moderate
contractions) and the block is coloured in completely if the contractions last 40
seconds or longer (i.e. strong contractions).
Recording the frequency of contractions
The number of contractions occurring within 10 minutes is recorded by
marking off 1 block for each contraction, e.g. 2 blocks marked off equals 2
contractions in 10 minutes, 4 blocks marked off equals 4 contractions in 10
minutes, and 5 blocks if 5 or more contractions in 10 minutes.

20. 1. The name of the drug.
2. The dose of the drug given.
3. The time the drug was given.
4. The type of intravenous fluid.
5. The time the intravenous fluid was started.
6. The rate of administration.
7. The amount of intravenous fluid given (after
completion).