ppt on Labour dystocia sept 2023

2. Introduction
• Normal labor progression –Dr Nasreen
• Labor Dystocia –Dr Tejaswini
• Labor care guide –Dr Prashanthi

3. • Case 1
• A primi with 40 weeks POG admitted at labor pains
on 13-9-2023 at 8AM. At admission her CTG was
reactive and she was having uterine contractions of
1-2/min and on pervaginal examination cervix was
50% effaced, os 2cms dilated. At 8PM she was
having the same findings and her CTG was reactive.
At 4 AM,on examination cervix was fully effaced,
os 2cms dilataion presenting part vertex at -3
station.At 8AM same findings.
– What is your diagnosis and how do you manage the case?

4. • Case 2
• A primi gravida with 40 weeks 6 days POG in
ROT position on induction on 13-9-2023. At start
of induction her Bishop score was 0 on 13-9-23
at 5AM.after 3doses ,on 14-9-23 her PV findings
were cervix fully effaced os- 2cms dilatation,at
12pm, os 6cms dilatation presenting part vertex at
-2 station.At 4pm cervix is fully effaced os 8cms
dilatation presenting part vertex at-1 station.
– What is your diagnosis and how do you manage the
case?

5. • Case 3
• A primi gravida with 40 weeks 6 days POG on
induction on 13-9-2023. At start of induction her
Bishop score was 0 on 13-9-23 at 5AM.after 3doses
,on 14-9-23 her PV findings were cervix fully effaced
os- 2cms dilatation,at 12pm, os 6cms dilatation
presenting part vertex at -2 station oxytocin
augmentation started.At 4pm she is having 3-4
uterine contractions in 10 mins,cervix is fully effaced
os 6cms dilatation presenting part vertex at-2 station
and aminiotomy done.at 8PM,cervix is fully
effaced,os -6cms dilatation and presenting part at -2
station.
– What is your diagnosis and how do you manage the case?

6. • Case 4
• A primi gravida with 40 weeks 6 days POG with
ROT on induction on 13-9-2023. At start of
induction her Bishop score was 0 on 13-9-23 at
5AM.after 3doses ,on 14-9-23 her PV findings were
cervix fully effaced os- 2cms dilatation,at 12pm, os
6cms dilatation presenting part vertex at -2 station
with spontaneous rupture of memebranes ,no caput.
4pm,cervix is fully effaced os full dilatation
presenting part vertex at-1 station with small skin
fold caput.
– at 5PM, on examination os is full dilated and presenting
part station at -1 and caput at 0 station
– What is your diagnosis and how do you manage?

7. • Labor is the process that leads to child birth
which begins with the onset of regular uterine
contractions and ends with delivery of fetus &
expulsion of placenta.

8. Stages of labor
• First stage : stage of cervical effacement &
dilatation
– Latent phase
– Active phase
• Second stage: stage of fetal descent & delivery
• Third stage: stage of placental separation &
expulsion
• Fourth stage: stabilization of mother & fetus

9. First stage
• Regular uterine contractions
– Uterine activity can be assessed by duration
&frequency of contraction.
– Adequate uterine contractions:3-5 contractions
lasting 40 seconds for every 10minutes

10. Montevideo units: calculated by subtracting the
baseline uterine pressure from the peak contraction of
each contractions in 10 mins period taking sum of these
pressures gives the value.
Normal value 200-250 MVUs

11. • Cervical effacement &dilatation

12. Latent phase
• Starts with regular uterine contractions and
cervical effacement & dilatation ends when
cervical dilatation reaches 6cms.

13. • Concept of a latent phase has great
significance in understanding normal human
labour, because labour will be considered
longer when a latent phase is included.
• Latent phase prolongation did not adversely
influence fetal or maternal morbidity or
mortality rates.

14. Active Phase
• Starts when cervical dilatation reaches 6cms
• Cervical dilation of 3 to 6 cm or more, in the
presence of uterine contractions, can be taken to
reliably represent the threshold for active labour.

15. Friedman’s theory
• Friedman (1954) described a characteristic sigmoid
graphical pattern of cervical dilatation against time.
• With Friedman's concept, the first stage of labour
contains three functional labour divisions.
• Preparatory phase
• Dilatation phase
• Pelvic division

16. Two phases of cervical dilation are defined.
Latent phase – corresponds to preparatory division
Active phase – corresponds to dilatation division
Acceleration phase
Phase of maximum slope
Deceleration phase

19. • Zhang and associates (2010) studied electronic
labour records from 62,415 parturients with
spontaneous labour at term and vaginal birth.
• They found that normal labour may take more
than 6 hours to progress from 4 to 5 cm and more
than 3 hours to progress from 5 to 6 cm dilation.
• Labor progression is gradual at a rate <1cm/hr
until cervical dilatation reaches 5-6cms and a
deceleration phase is not observed.

22. • Depicts a relatively slow rate of
cervical dilatation until
approximately 4 cms
• Followed by an abrupt acceleration
in the rate of dilation until entering
a
• deceleration phase at
approximately 9cms
• An increase in the rate of cervical
dilation gradual as labour
progresses until it reaches 6cms
• No abrupt change in rate of
dilatation
• No deceleration phase
Zhang
curve

24. Second Stage of Labour
• Stage begins with complete cervical
dilation and ends with fetal delivery.
• Fetal descent largely follows
complete dilatation.
• Speed of descent is maximum after
complete cervical dilatation.
• The median duration
– 50 minutes for nulliparas
– 20 minutes for multiparas(Kilpatrick, 1989).

26. • What does effective uterine contractions
mean?
Answer 3-4 contractions each lasting for 40
seconds in 10 minutes duration.

27. • When Latent phase ends, what is the cervical
dilatation?
Answer 6 centimeters

28. • Why end of latent phase changed from 4cms to
6cms?
normal labour may take more than 6 hours to
progress from 4 to 5 cm and more than 3 hours to
progress from 5 to 6 cm dilation.

29. • Difference between Friedman’s curve and
Zhang curve?
Friedman’s curve
• Depicts a relatively slow
rate of cervical dilatation
until approximately 4
cms
• Followed by an abrupt
acceleration in the rate of
dilation until entering a
• deceleration phase at
approximately 9cms
Zhang curve
• An increase in the rate of
cervical dilation gradual
as labour progresses until
it reaches 6cms
• No abrupt change in rate
of dilatation
• No deceleration phase

30. Dystocia
Dystocia literally means “difficult labor” or “
dysfunctional labour”; abnormally slow labor progress
Labor dystocia is the leading indication for cesarean
section
Causes are grouped into 3 distinct categories
POWER : poor uterine contractility, maternal
expulsive effort
PASSENGER : the fetus
PASSAGE :the pelvis and the lower reproductive tract

31. Causes of Dystocia
FETAL
CHARACTERISTICS
• Presentation:
Face,Brow,
• Position:
Occiput Transverse,
Occiput posterior,
Asynclitism
• Macrosomia
• Undiagnosed
anomalies
INTRAPARTUM
FINDINGS:
• Hydramnios,Chorioa
mnionitis,Neuraxial
analgesia,Higher
station at labor
onset
• Poor maternal
pushing :
sedation,severe
pain,dense regional
block,neurologic
disease
MATERNAL
CHARACTERISTICS:
• Nulliparity,increasing
age,Obesity,
• Anthropoid, android
or platypelloid pelvis
types
• Narrow pelvic
dimensions, Short
stature, Pelvic
Tumor

32. 1st “P” POWER
ABNORMALITIES OF THE
EXPULSIVE FORCE:
Hypotonic uterine contractions:
● Basal tone is normal
● Uterine contractions have a normal gradient pattern (synchronous)
● Pressure during contraction is insufficient to dilate the cervix
● Good relaxation in between contractions
● The contractions are not very painful
Causes:
● Most common cause : Cephalo pelvic disproportion
● Epidural analgesia
● Chorioamnionitis
● Nullipara
● Dehydration, Exhaustion
● Over distension of uterus …. Polyhydramnios,multifetal pregnancy

33. Management:
● Correct maternal dehydration & Emotional
support
● Rule out CPD
● Augmentation with oxytocin
● Amniotomy

34. Hypertonic uterine dysfunction: (incoordinate uterine dysfunction)
● Basal tonus is elevated
● Pressure gradient is distorted
-Gradient distortion may result from more forceful contraction of the uterine
mid segment than the Fundus or from complete asynchrony of the impulses
originating in each cornua or a combination of these two.
Causes:
● Injudicious usage of oxytocin
● Effects on Labour :
● Uterine contractions are irregular & more painful
● Slow cervical dilatation
● Labor is prolonged
● Premature rupture of membranes
● Fetal & Maternal distress

35. ● Treatment:
● Stop Oxytocin infusion
● Maternal Hydration
● Analgesics
● Monitor vitals & FHR
● Rule out CPD
● If Contractions are still ineffective
….Augmentation with oxytocin
Amniotomy

37. 2nd “P” PASSAGES
Fetopelvic Disproportion
● Fetopelvic disproportion arises from diminished
pelvic capacity or excessive fetal size
● There may be a contraction of the pelvic inlet ,
the mid pelvis, or the pelvic outlet , or generally
contracted pelvis may be caused by
combinations of these.

38. Inlet contraction:
Anteroposterior diameter <10cm/ obstetric conjugate
Effects on fetus
• Failure of engagement
• Increase in malpositions.
• Deflexion attitudes.
• Exaggerated asynclitism.
• Extreme molding
• Formation of large caput
succedaneum
• Prolapse of the umbilical
cord
Effects on Labor
• Cervical dilatation is
often slow &
incomplete
• Premature rupture of
membranes
• Insufficient uterine
action

39. Midpelvic contraction:
● Sum of interspinous diameter & posterior
saggital diameters ≤13.5cm
● Interspinous diameter <8cm
Mid pelvic contraction may prevent anterior
rotation of the occiput & may direct it into the
hallow of the sacrum.
Failure of rotation & deflexion attitudes are
associated frequently with a small pelvic cavity.

40. Outlet contraction:
● Interischial spine diameter of 8 cm or less
It is associated with mid pelvis contraction
Contracted outlet often gives rise to perineal
tears.

41. 3rd “P” PASSENGER
Fetopelvic Disproportion
● Fetopelvic disproportion can also arise from
large fetal head size , or malposition of the fetal
head ( includes asyncyltism,Occiput posterior
position, face or brow presentation)

42. First stage disorders:
Prolonged Latent Phase
• Defined as LATENT PHASE >20 hrs in nulliparas; >14hrs in
multiparas
• False labor & latent phase of labor initially share similar
characteristics
• However the contractions & cervical changes associated with latent
labor become stronger,more regular, & more frequent over time
where as the Braxton- Hicks contractions associated with false labor
diminish in frequency & intensity

43. Risk factors :
Unripe cervix, Occiput transverse or posterior position
Abnormal uterine action
Treatment:
1. Expectant management is usually done until there is indication
(for the fetus or the mother) for expediting the delivery
2. Rest and analgesic are usually given
3. When Augmentation is decided, medical methods (oxytocin or
prostaglandins) are preferred
4. Amniotomy
5. Prolonged latent phase is not an indication for cesarean
delivery

44. Divided into either
● Protraction disorder : slower than normal progress
● Arrest disorder: complete cessation of progress
A woman must be in the active phase of labor with cervical dilatation
>6cm
First stage disorders
Active phase disorders ( Dilatation
disorders)

45. Active phase protraction
● WHO defined as rate of cervical dilatation less
than 1 cm/hr for a minimum of 4 hours
Causes:
1. Ineffective contractions
2. Deflexed head
3. Malposition
4. CPD

46. Management:
1. Rule out CPD
2. Observation for further progress is appropriate
treatment
3. In case of hypotonic uterine
contractions….Augmentation with oxytocin
4. Amniotomy
5. Slow but progressive first stage of labor SHOULD not
be an indication for cesarean delivery
Cesarean delivery should be reserved for women at or
beyond 6 cm dilatation with ruptured membranes who fail
to progress despite 4 hrs of adequate uterine activity

47. Active Phase Arrest / Arrest of dilatation
Diagnosis of active phase arrest is made with ruptured
membranes, cervical dilatation >- 6 cm & one of the
following
● No cervical change for >_ 4 hrs despite adequate uterine
contractions ( defined as > 200 MV units in a 10 minute
window period)
● No cervical change for >_ 6 hrs of oxytocin
administration with inadequate contractions
Labor arrest in active phase is managed by cesarean delivery

49. Obstetric care Consensus committee
(2016)
4 Recommendations of the Consensus Committee apply to
management of
First stage labor
Recommendation 1 :
A prolonged latent phase is not an indication for cesarean
delivery
Recommendation 2 :
A slow but progressive labor (protraction disorder) is NOT
an indication for cesarean delivery

50. Recommendation 3 :
Active phase of labor starts at cervical dilatation of 6 cm… not 4
cm
More over before this threshold standards for active phase
progress should not be applied
WHO recognizes 5 cm as the active labor threshold
Recommendation 4 :
Caesarean delivery for active phase arrest should be reserved for
women at or beyond 6 cm of cervical dilatation with ruptured
membranes, who fail to progress despite 4 hrs of adequate
activity or at least 6 hrs of oxytocin administration

51. Second stage descent disorder
● In Nulliparous woman, the diagnosis of prolonged second stage
should be considered
when the second stage exceeds 2 hours without epidural anesthesia
Or 3 hrs with epidural anesthesia
● In Multiparous women , the diagnosis can be made
when the second stage exceeds 1 hours without epidural anesthesia
Or 2 hrs with epidural anesthesia

52. ● Consensus committee (2016) recommends allowing a
nullipara to push at least 3 hrs & a multipara to push
for at least 2 hrs before 2nd stage labor arrest is
diagnosed
- Maternal & Fetal status should be reassuring

53. Pit falls in prolongation of second
stage
● Maternal outcomes like chorioamnionitis,operative vaginal
delivery ,difficulty in cesarean delivery, anal sphincter
injury,postpartum hemorrhage may result as the second stage
lengthens
● It is problematic that no data on neonatal outcomes support the
safety of outcome of allowing prolonged second stage labor
● Data from many evaluations reveal that serious newborn
consequences attend second stage labors longer than 3 hrs
● Goal to lower cesarean delivery rates is best balanced with one
to ensure neonatal safety

54. Management:
● Rule out CPD
● Slow descent in the second stage is managed with
oxytocin if the uterus is hypocontractile
● Intervention is not indicated as long as descent or
rotation to a more favourable position is occurring & the
FHR pattern is reassuring
● Operative intervention is indicated for fetuses with
abnormal FHR tracings, regardless of labor progress
● Second stage arrest is an indication for operative
delivery (instrumental or cesarean delivery)

55. PRECIPITATE LABOR
● When the combined duration of first & stage less
than < 3 hours
● Short Labors may be associated with : placental
abruption, uterine tachysystole
● Rapid expulsion is due to combined effect of
hyperactive uterine contractions associated with
diminished soft tissue resistance
● Labor is short as the rate of cervical dilatation is 5
cm / hr or more for the nulliparous women

56. Maternal risks:
1. Extensive laceration of the cervix, vagina & perineum
2. PPH due to uterine hypotonia that develops subsequent to
vigorous contractions
3. Uterine Inversion
4. Uterine rupture
5. Infection
Fetal risks:
1. Intracranial stress & hemorrhage because of rapid expulsion
without time for molding of the head
2. The baby may sustain serious injuries if delivery occurs in
standing position; bleeding from the torn cord & direct hit on
the skull

57. Treatment:
● The patient having previous history of precipitate labor
should be hospitalises before labor
● Use of tocolytic agents such as Magnesium sulphate or
terbutaline is unproven in these circumstances
● Terbutaline 250 micrograms intramuscular may be
given in an attempt to resolve a non reassuring fetal
heart rate pattern
● Oxytocin augmentation should be avoided
● Delivery of the head should be controlled
● Episiotomy should be done liberally

58. ● Descent is occurring
● Previous vaginal birth
● Absence of comorbidities that are likely to impact labor
● Pelvis is adequate for vaginal birth
● Patient is not short (height < 160 cm) or obese (BMI >_ 30 mg / kg)
● Fetus is OA , with minimal caput & molding
● Station is at least + 2 / 5 cm
● Absence of maternal fever, which is presumptive of chorioamnionitis
● Estimated fetal weight is appropriate for gestational age (< 95 th
percentile)
● Pushing appears to be effective & the patient is not exhausted
● Category 1 Fetal heart rate pattern
● Patient desire to proceed with labor
Clinical factors associated with increased
chances of safe vaginal delivery include

59. Ineffective management interventions
1. Turning down the epidural
2. Changing maternal position
3. Fundal pressure

60. Case 1
● A primi with 40 weeks POG admitted at labor pains on
13-9-2023 at 8AM. At admission her CTG was reactive
and she was having uterine contractions of 1-2/min and
on pervaginal examination cervix was 50% effaced, os
2cms dilated. At 8PM she was having the same findings
and her CTG was reactive. At 4 AM,on examination
cervix was fully effaced, os 2cms dilataion presenting
part vertex at -3 station.At 8AM same findings.
○ What is your diagnosis and how do you manage the case?

61. Rule out false labor pains
Diagnosis is prolonged latent phase of labor.
Treatment : watchful expectancy
rest and analgesia
augmentation is decided

62. Case 2
A primi gravida with 40 weeks 6 days POG in ROT
position on induction on 13-9-2023. At start of induction
her Bishop score was 0 on 13-9-23 at 5AM.after 3doses
,on 14-9-23 her PV findings were cervix fully effaced os-
2cms dilatation,at 12pm, os 6cms dilatation presenting
part vertex at -2 station.At 4pm cervix is fully effaced os
8cms dilatation presenting part vertex at-1 station.
What is your diagnosis and how do you manage
the case?

63. Diagnosis: prolonged active phase
Treatment : observation , rule out cephalo pelvic disproportion
At 12pm,when os is >6cms dilated,check for adequate uterine
contractions., if there are no adequate uterine contractions start
oxytocin drip
At 4pm,when os is 8cms dilated,Aminiotomy clear liquor
later at 5 pm oxytocin is started.
Till 8 PM, oxytocin drip is titrated,and uterine activity and
CTG is assessed.
As there is no progression even after 4hours and amniotomy
with adequate uterine contractions CESAREAN
SECTION.

64. Case 3
A primi gravida with 40 weeks 6 days POG on induction on
13-9-2023. At start of induction her Bishop score was 0 on
13-9-23 at 5AM.after 3doses ,on 14-9-23 her PV findings
were cervix fully effaced os- 2cms dilatation,at 12pm, os
6cms dilatation presenting part vertex at -2 station oxytocin
augmentation started.At 4pm she is having 3-4 uterine
contractions in 10 mins,cervix is fully effaced os 6cms
dilatation presenting part vertex at-2 station and aminiotomy
done.at 8PM,cervix is fully effaced,os -6cms dilatation and
presenting part at -2 station.
What is your diagnosis and how do you manage the case?

65. Diagnosis : active phase arrest
of dilatation
CESAREAN SECTION

66. Case 4
A primi gravida with 40 weeks 6 days POG with ROT on
induction on 13-9-2023. At start of induction her Bishop
score was 0 on 13-9-23 at 5AM.after 3doses ,on 14-9-23
her PV findings were cervix fully effaced os- 2cms
dilatation,at 12pm, os 6cms dilatation presenting part
vertex at -2 station with spontaneous rupture of
memebranes ,no caput. 4pm,cervix is fully effaced os full
dilatation presenting part vertex at-1 station with small
skin fold caput.
What is your diagnosis and how do you manage?

67. Diagnosis : second stage descent disorder.
If CTG is reactive, with inadequate uterine
contractions  start oxytocin drip.
check for saggital suture position ,alert senior
obstetrician  go for CESAREAN SECTION if
there is no further descent even after one hour.

68. identify the tone of uterus
Normal

69. Hypertonus

70. Hypotonus

71. 2
1. WHO recommendations on intrapartum care
for a positive childbirth experience.
2. WHO Labour Care Guide: the next
generation partograph

72. Labour Care Guide: Why?
 To improve every woman’s experience of childbirth
 To help ensure the health and well-being of women
and baby by facilitating the effective implementation
of the WHO intrapartum care recommendations.
 To establish essential good quality and evidence-
based clinical care in all settings.
 To expand the focus of Labour monitoring to non-
clinical practices that promote a positive childbirth
experience for every woman and baby.

73. WHO Labour Care Guide: Aims
• Guide the monitoring and documentation of the
well-being of women and babies and the progress of
labour.
• Guide health personnel to offer supportive care
throughout labour to ensure a positive childbirth
experience for women.
• Assist health personnel to promptly identify and
address emerging labour complications.
• Prevent unnecessary use of interventions
in labour.
Support audit and quality improvement of labour
management.

74. Guiding principles :
 Labour and childbirth should be
individualized and woman-centred
 No intervention should be
implemented without a clear
medical indication
 Only interventions that serve an
immediate purpose and proven to
be beneficial should be promoted
 A clear objective that a positive
childbirth experience for the
woman, the newborn and her family
should be at the forefront of labour
and childbirth care at all times
7
4

75. • WHO Labour Care Guide: the next generation partograph

76. Structure of the
WHO Labour Care
Guide
The Labour Care Guide has 7
sections, which were adapted from
the previous partograph design:
Section 1: Identifying information
and labour characteristics at
admission
Section 2: Supportive care
Section 3: Care of the baby
Section 4: Care of the woman
Section 5: Labour progress
Section 6: Medication
Section 7: Shared decision-making
These sections contain a list of
labour observations.

77. Section 1: Identifying information
and labour characteristics at
admission
woman’s name and labour
admission characteristics
• Parity
• mode of labour onset
• date of active labour diagnosis
• date and time of rupture of
membranes
• risk factors
This section should be completed
with the information obtained when
active labour diagnosis is
confirmed.
7
7

78. Section 2: Supportive
care
• Respectful maternity care (RMC)
is a fundamental human right of
pregnant women and is a core
component of the WHO
intrapartum care recommendations.
• Section 2, aims to encourage the
consistent practice of RMC.
• The supportive care section
includes,
o labour companionship.
o access to pharmacological and non-
pharmacological pain relief.
o ensuring women are offered oral
fluid.
o techniques to improve women’s
comfort.
7
8

79. Section 3: Care of the
baby
7
9
• to facilitate decision-making while
monitoring the well-being of the
baby.
• Regular observation of baseline
fetal heart rate (FHR) and
decelerations in FHR.
• Amniotic fluid
• Fetal position.
• Moulding of the fetal head.
• Development of caput
succedaneum.

80. Importance of fetal position:
• During labour with the descend ,the fetal
head rotates so that the fetal occiput is
anterior in maternal pelvis , failure to rotate
and fetal occiput in transverse or posterior
should be managed as abnormal fetal
position

81. CAPUT SUCCEDANEUM
In prolonged labour before complete cevrical
dilatation, the portion of fetal scalp immediately
over the cervical os becomes edematous called as
caput succedaneum. Graded as 0,+, ++,& +++
depends on severity.

82. MoulMoulding:
• Assess the shape of fetal skull and degree of overlapping
fetal head bones during labour
• Graded as grade 0,+,++,+++,
• Grade +++ is an alert condition

83. Section 4: Care of the
woman
8
3
• To facilitate decision-
making for consistent and
intermittent monitoring of
the women’s well being.
• Pulse
• Blood pressure
• Temperature
• Urine.

84. Section 5: Labour
progress
• aims to encourage the systematic
practice of intermittent monitoring
of labour progression parameters.
• frequency and duration of
contractions
• cervical dilatation.
• descent of the baby’s head.
8
4

86. • Uterine Contractions:
• Count the number of uterine contractions over a 10 minute
period.
• Alert: ≤2, >5
• If contractions are inefficient, suspect inadequate uterine
activity . Continuous contractions are a sign of obstructed
labour.
• If contractions are ≤2 or >5 per 10 minutes, verify the number
of contractions over another 10 minutes. If frequency is
confirmed, alert a senior care provider and follow clinical
guidelines.
• If contractions are 3–5 per 10 minutes, assess uterine
contractions every 30 minutes during the first stage of labour
and at least every 15 minutes during the second stage.

87. • Duration of Contractions
• Assess the duration of contractions.
• Record duration of contraction in seconds.
• Alert: <20, >60
• Short contractions could indicate inadequate uterine activity. More
than five contractions in 10 minutes or continuous contractions are
signs of obstructed labour or hyperstimulation .
• If contractions last <20 or >60 seconds.verify the number of
contractions over another 10 minutes. If duration is confirmed,
alert senior provider and follow local clinical guidelines.
• If contractions last ≥20 or ≤60 seconds, assess contractions every
30 minutes during the first stage of labour and at least every 15
minutes during the second stage.

88. • Cervix dilatation:
• Perform gentle vaginal examination, after obtaining the
woman’s consent and ensuring privacy. Use aseptic
technique to examine the cervix. Do not start the
examination during a uterine contraction. Assess all
parameters that require a vaginal examination at the same
time.
• In the active first stage of labour, plot “X” in the cell that
matches the time and the cervical dilatation each time you
perform a vaginal examination. In the second stage, insert
“P” to indicate when pushing begins.

89. • Alert values for first stage:
• 5 cm = ≥6 h (cervical dilatation remains at 5 cm for 6 or more hours)
• 6 cm = ≥5 h (cervical dilatation remains at 6 cm for 5 or more hours)
• 7 cm = ≥3 h (cervical dilatation remains at 7 cm for 3 or more hours)
• 8 cm = ≥2.5 h (cervical dilatation remains at 8 cm for 2.5 or more hours)
9 cm = ≥2h (cervical dilatation remains at 9 cm for 2 or more hours)
• Alert value for second stage: ≥3h in nulliparous women; ≥2h in
multiparous women
• Alert triggered when lag time for current cervical dilatation or in second
stage is exceeded with no progress.
• During the first stage, if labour progresses as expected, assess cervical
dilatation every 4 hours unless otherwise indicated.

90. • Descent
• Assess descent by abdominal palpation; refer to the part of the head (divided into five
parts) palpable above the symphysis pubis.
• Plot “O” in the cell that matches the time and the level of descent. Plot an “O” at
every vaginal examination. 5/5, 4/5, 3/5, 2/5, 1/5 and 0/5 should be used to describe
the fetal station by abdominal palpation
• There are no reference thresholds for this observation, which will vary on each
individual case.
• During first stage, assess descent every 4 hours before performing vaginal
examination, unless otherwise indicated.
• During the second stage, take into account the woman’s behaviour, effectiveness of
pushing, and baby’s position and well-being when deciding the timing of descent
assessment.

91. • Abdominal assessment of progressive descent of the head(using fifth formula)
• Progressive descent of the head can be usefully assessed abdominally by estimating
the number of “fifths” of the head above the pelvic brim (Crichton). The amount of
head felt suprapubically in finger breadth is assessed by placing the radial margin
of the index finger above the symphysis pubis successively until the groove of the
neck is reached. When one-fifth above, only the sinciput can be felt abdominally
and nought-fifth represents a head entirely in the pelvis with no poles felt
abdominally.
• Advantages over “station of the head” in relation to ischial spines
• 1. It excludes the variability due to caput and molding or by a different depth of
the pelvis.
• 2. The assessment is quantitative and can be easily reproduced.
• 3. Repeated vaginal examinations are avoided.

92. Section 6: Medication
 Aims to facilitate consistent recording of all types of medication used
during labour.
• Oxytocin and its dose.
• other medications
• IV fluids
92

93. Section 7: Shared decision-making
9
3
• Aims to facilitate continuous
communication with the
woman and her companion.
• The consistent recording of all
assessments and plans agreed.
• Effective communication using
simple and culturally
appropriate language.
• Clear explanations of procedures
and their purpose should always
be provided to each woman.
• The findings of physical
examinations should be explained
to the woman and her
companion.
• Subsequent course of action
made clear to enable shared
decision- making.

94. How to use the Labour Care Guide:
Labour monitoring to action
The Labour Care Guide creates a positive feedback and decision-
making loop, as health personnel are encouraged to regularly:
• Assess assess the well-being of woman and her baby, and progress
of
labour
• Record document labour observations
• Check reference threshold compare labour observations with
reference
values in the “Alert” column
• Plan decide whether and what interventions are
required, in consultation with the woman, and document
accordingly
 It encourages critical thinking.
 Avoids unnecessary interventions.
 Acts on warning signs.
The Labour Care Guide includes a section to document shared decisions to