asssessment of labor with labelling of parto

2. The process of labor

3. Progression of the labor
 What are the expectations for the progress of normal labor?
 A scientific approach was begun by Friedman 1954, who
described a characteristic sigmoid pattern for labor by
graphing cervical dilatation against time.

4. Friedman’s Curve
 Friedman's Curve describes progress of two variables over time: dilation of cervix
and descent of baby.
 Labor is “dysfunctional” when cervix stops dilating or fetal descent stops or both.
 Possible diagnosis of "failure to progress"
 C-section indicated.
 Maybe due to CPD (cephalo pelvic disproportion or epidural anesthesia (can slow
labor).

5. Friedman labor curve
 First stage = A + B + C + D where
 A=latent phase
 B=acceleration phase
 C=phase of maximum slope
 D=deceleration phase
Second stage = E

6. FRIEDMAN’S CURVE

7. STAGES OF THE LABOR
 Labor and delivery are divided into three stages. Each stage
involves different concerns and considerations.
1. First stage
2. Second stage
3. Third stage
N.B: some books add Fourth stage which is the early recovery

8. The First stage
1. Stage of cervical effacement and dilatation.
 First stage is characterized by cervical dilatation and
effacement and lasts from the onset of the labour until
full dilatation.
 The first stage can be divided functionally into two phases:
1. the latent phase and
2. the active phase. .
 Duration:
o Primigravida = 8-12 h
o Multigravida = 6-8 h
 Uterine contractions are the only force that acts cervical
dilatation

9. The First stage
Latent phase:
describes the progress of labour from 0 cm to 3—4 cm
dilatation.
The onset of the latent phase is the point when the mother
perceives painful uterine contractions.
A. in primigravida = 8h
B. in Multigravida = 4h

10. The First stage
Women in latent phase labor:
Are less than 4 cm dilated.
Have regular, frequent contractions that may or may
not be painful.
May find their contractions wax and wane dilate only
very slowly.
Can usually talk or laugh during their contractions
May find this phase of labor lasting hours to days or
longer.

11. The First stage

12. The First stage
Active phase:
Active phase labor is a time of rapid change in cervical dilatation,
effacement , and station and lasts until the cervix is completely
dilated.
This phase is normally characterized by progress of at least 1cm
per hour.
≥1.2cm/hr primigravida
≥1.5cm/hr multigravida
Active phase: rapid dilatation of the cervix to reach 10cm
in primigravida = 4h
in multigravida =2h

13. The First stage
Active phase:
Women in active phase labor:
 Are at least 4cm dilated
 Have regular , frequent contractions that are usually moderately painful
 Demonstrate progressive cervical dilatation of at least 1.2-1.5 cm per hour.
 Usually are not comfortable with talking or laughing during their contractions
 Cardinal movements of labor:
1. Engagement.
2. Descent
3. Flexion
4. Internal rotation(
5. Extension
6. External rotation (restitution)
7. Expulsion

14. The active phase is divided into:
1. Accelerative phase
2. Slopping phase
3. Decelerative:
A. prolonged active phase
B. primary dysfunction: dilation in active phase
of<1cm/hr
C. secondary arrest: active phase dilation stops or
slow significantly.
N.B – in primigravida the cervix dilates from above
downwards, in multigravida dilatation of the internal
os, taking up of the cervix and dilatation of the external
os occurs simultaneously.

15. FRIEDMAN LABOR CURVE

16. Factors affecting cervical dilatation:
1. Contraction and retraction of the uterus.
2. The bag of fore-water.
3. Absence of membranes.
4. Fitting of the presenting part to the lower segment
and the cervix.
5. Pre-labour changes in the cervix (e.g., softening)

17. 2-The second stage
Stage 2 is from the time of full dilation until delivery of the infant. Its
involves the expulsion of the foetus.
 Duration:
1 hour in primigravida
½ hour in multipara.
 ‘Passive second stage’ refers to the period defined above but in
the absence of pushing (normally to allow descent of the foetal head
prior to pushing)
‘Active second stage’ refers to the active process of maternal
pushing directed to achieving delivery.

18. The third stage
 Third stage is characterized by delivery of the placenta and extends from
delivery of the baby to delivery of the placenta and membranes.
 Duration: 30min in all women
 Stage 3 depends on myometrial contraction
 Signs of stage 3:
A. Gush of fluid vaginally
B. Change of uterus from long to globular
C. Lengthening of the umbilical cord
D. Uterus becomes firmer

19. The fourth stage
Stage 4: The hour immediately following delivery
Postpartum hemorrhage as a result of atony may
occur

21. 7 Labor Dysfunctions
1. Prolonged Latent Phase
 Definition:
 > 20 hours nullipara
 > 14 hours multipara
 Causes : 3P (inadequate uterine contraction, analgesia)
Treatment: “
 Therapeutic rest” = sedatives
 85% awaken in 6-10 hours and progress to active phase
 10% have stopped contracting
 5% continue to contract without progression, requiring uterine stimulation.
 Oxytocin or aminiotomy
 C/S in never done in latent phase

22. 7 Labor Dysfunctions
1. Labor Dysfunctions Protracted Active Phase
Definition:
Cervical dilation < 1.2 cm/h nullipara
Cervical dilation < 1.5 cm/h multipara
Treatment:
 Evaluate passenger, passageway, power
 IUPC to calculate MVU (goal > 200)
 Oxytocin augmentation +ARM
Minimum dilation should be 1cm/hr

23. 7 Labor Dysfunctions
1. Protracted Deceleration Phase
Definition:
 > 3 hours nullipara >
 1 hour multipara
Treatment:
 Same as for protracted active phase
 Evaluate passenger, passageway, power
 IUPC to calculate MVU (goal > 200)
 Oxytocin augmentation

24. Labor Dysfunctions
1. Secondary Arrest of Dilatation in active phase (Active phase arrest)
Definition:
If membranes rupture and cervical dilation has not changed for
 ≥4hrs with adequate uterine contraction or ≥6hrs of IV oxytocin with in adequate uterine contraction
Causes: 3P Abnormalities: power( inadequate uterine contraction)
pelvic (CPD)
passenger ( excessive fetal, abnormal orientation)
Treatment: assess uterine contraction
If contractions : IV oxytocin Two prerequisities to say arrest:
If contractions : morphine 1) membrane should rupture
If contractions adequate : C/S 2) uterine contraction should be
adequate
Adequate uterine contraction: 3 contraction in 10 min ≥45sec IUP 65-75mmHg (220MVU)

25. Labor Dysfunctions
1. Protracted Descent
Definition:
 < 1 cm/h nullipara
 < 2 cm/h multipara
 Treatment:
1. Same as for protracted active phase
2. Evaluate passenger, passageway, power
3. IUPC to calculate MVU (goal > 200)
4. Oxytocin augmentation or ARM

26. Labor Dysfunctions
 Arrest of Descent in Second Stage
Definition:
After complete cervical dilation
No descent of presenting part in:
 2 hours (or > 3 hours with CLE) nullipara
 > 1 hour (or > 2 hours with CLE) multipara
Causes : 3P
Treatment:
Power :
maternal uterine contraction : IV oxytocin
Maternal pushing : Enhanced couching
(≥+2) engaged : vaginal delivery (forceps or vacuum)
(<+2) not engaged : C/S

27. Labor Dysfunctions
Failure of Descent
Definition:
 No descent in > 1 hour nullipara
 No descent in > 30 min multipara
Treatment:
 Same as for protracted active phase
 Evaluate passenger, passageway, power
 IUPC to calculate MVU (goal > 200)
 Oxytocin augmentation

28. Prolonged third stage
 Definition:
Failure to deliver placenta with in 30 min
 Causes:
Inadequate uterine contraction
Abnormal placenta implantation ( placenta accrete, increta,
percreta)
 Treatment:
IV oxytocin
Manual removal

29. Labor Assessment Case 1

 32 year G1P0 36 weeks presented with contractions.
Looks uncomfortable, and is contracting every 3
minutes but cervix is 2 cm and 50% effaced. Was seen
the previous day with similar complaints and findings.
 Diagnosis:
 Management:

30. Labor Assessment Case 1
 32 year G1P0 36 weeks presented with contractions.
Looks uncomfortable, and is contracting every 3
minutes but cervix is 2 cm and 50% effaced. Was seen
the previous day with similar complaints and findings.
 Diagnosis:
 Prolonged latent phase
 Management:
 “ Therapeutic Rest”

31. Labor Assessment Case 2
 24 year P1001 39 weeks presented in labor. Contracting
every 3 minutes but looks comfortable. Progressed
from 4 to 6 centimeters in 6 hours. Membranes intact.
Estimated fetal weight – 3000 grams. Pelvis adequate
on examination. Vertex presentation.
 Diagnosis:
 Management:

32. Labor Assessment Case 2
 24 year P1001 39 weeks presented in labor. Contracting
every 3 minutes but looks comfortable. Progressed
from 4 to 6 centimeters in 6 hours. Membranes intact.
Estimated fetal weight – 3000 grams. Pelvis adequate
on examination. Vertex presentation.
 Diagnosis:
 Protracted active phase likely secondary to inadequate labor
(insufficient power)
 Management:
 Amniotomy, Oxytocin augmentation +/- IUPC

33. Labor Assessment Case 3
 Labor Assessment Case 3 32 year P0000 Class C
diabetic at 40 weeks undergoing labor induction.
Contracting every 2-3 minutes. 7 cm dilation x 4
hours. Confirmed adequate labor with intrauterine
pressure catheter. Membranes ruptured, Estimated
fetal weight – 4200 grams. Pelvis adequate on
examination. Vertex presentation.
 Diagnosis:

34. Labor Assessment Case 3
 Labor Assessment Case 3 32 year P0000 Class C
diabetic at 40 weeks undergoing labor induction.
Contracting every 2-3 minutes. 7 cm dilation x 4 hours.
Confirmed adequate labor with intrauterine pressure
catheter. Membranes ruptured, Estimated fetal weight –
4200 grams. Pelvis adequate on examination. Vertex
presentation.
 Diagnosis:
 Arrest of dilatation likely secondary to cephalopelvic
disproportion/fetal macrosomia (Passenger too big for pelvis)
 Management:
 Cesarean Delivery

35. Labor Assessment Case 4
28 year P0101 at 42 weeks presented in labor. History
of previous MVA with pelvic fracture. Contracting
every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed
adequate labor with intrauterine pressure catheter.
Membranes ruptured, Estimated fetal weight – 3200
grams. Constricted pelvic inlet with non-engaged fetal
head. Vertex presentation.

 Diagnosis:
 Management:

36. Labor Assessment Case 4
28 year P0101 at 42 weeks presented in labor.
History of previous MVA with pelvic fracture. Contracting
every 2-3 minutes. 6 cm dilation x 4 hours. Confirmed
adequate labor with intrauterine pressure catheter.
membranes ruptured, Estimated fetal weight – 3200 grams.
Constricted pelvic inlet with non-engaged fetal head.
Vertex presentation.
Diagnosis:
Arrest of dilatation likely secondary to cephalopelvic disproportion/abnormal
pelvis (Pelvis too small for pelvis)
Management: Cesarean Delivery

37. Question one
 A G2P1 is admitted in labor at 8 am on Monday
 A: p/v findings = Cervix 2cm dilated, 20% effaced
 B: At 10pm findings are : cervix =3cm dilated,60% effaced
 C: FHR: Regular, 140-146 bpm
 D: Membranes= intact
 E: What is the next management

38.  Dx: Prolonged latent phase
 Mgx: Therapeutic rest

39. Question Two

40.  Dx: Protracted active phase
 Causes: Evaluate 3P ( cant be CPD b/c prior delivery to
3800g infant)
inadequate uterine contraction
Mgx: Oxytocin Augmentation

41. Question three

42.  Dx: Secondary arrest of dilatation in active phase ( active
phase arrest)
 Mgx: C/S

43. Question Four

44.  Dx: latent phase
 Mgx: Observe the patient and wait for increase in uterine
contractions

45. Question Five

46.  Dx: Protracted active phase
 Cause: Evaluate 3P
good uterine contractions
Reassess for OPP and CPD