1. Management of Labor Family Medicine Specialist CME University of Health Sciences

2. Objectives For a woman presenting in labor: 1. Diagnose normal and abnormal labor patterns. 2. Describe how to manage a normal and abnormal labor. 3. Describe the use of the partograph to manage and monitor labor

3. Definitions Labor – Regular uterine contractions which causes cervical change of dilatation and effacement, resulting and delivery of one or more fetuses – Stages of Labor: First Stage: Cervical dilatation 0 – 10 cm – Latent – Active Second Stage: Full cervical dilatation to delivery of the fetus Third Stage: Delivery of fetus to delivery of placenta Fourth Stage: First 24 hours after delivery of pregnancy

4. Definitions Latent Labor – onset difficult to diagnose – Complete when cervix less than 1 cm in length and 3-4 cm dilated in nulliparous woman 4-5 cm dilated in parous woman Active Labor – Begins at end of latent labor and ends with complete cervical dilatation (10 cm) – Descent of fetus begins

5. Definitions Second Stage of Labor – Passive Cervix fully dilated and fetal descent in pelvis until the urge to push is felt (approximately +2 Station) – Active From onset of urge to push until delivery of fetus

6. Partograph – What Tool to assist in the management of labor and assess cervical dilatation and progress Other observations recorded: – Descent of fetal head – Uterine contractions – Maternal vital signs – Fetal well-being: Fetal heart rate Membranes and color of liquor Molding of fetal head

8. Partograph - Why Reduces – Prolonged labor – Need for augmentation – Emergency cesarean section rates – Intrapartum stillbirth rates

9. Partograph - How? Centre – Graph – Dilatation (0 – 10 cm/square) along the left side – Time (Each square equals 1 hour) along the bottom – Dilatation marked on the alert line corresponding time in the appropriate box – Repeated cervical dilatations recorded on the graph

10. Partograph – When to use Women in active labor: Cervix > 4 cm dilated Contractions: At least 2 in 10 minutes lasting at least 20 seconds in length Women with no complications requiring immediate action

11. Partograph: Action ALERT line - When dilatation moves to the right of the ALERT line – Amniotomy (if membranes are intact) should be performed and assess the woman assessed for progress of labor in an appropriate time frame – May require oxytocin augmentation or transfer to centre that can provide advanced care for woman

12. Partograph: Action (2) ACTION Line: If the progress of labor crosses to the right of the action line, intervention is required: – Oral or IV hydration – Empty the bladder – either the woman is encouraged to void or catheterization – Analgesia for woman – Augmentation of contractions with oxytocin – Close monitoring of cervical dilatation – Careful monitoring of fetal well-being

13. Abnormal Labor: Prolonged Latent Phase Assessment should take place in a triage area Woman should not be admitted until in active labor NO amniotomy Management should include – Ambulation – Rest – Analgesia – Woman should be educated about coping strategies and when to return for reassessment

14. Abnormal Labor: Prolonged Active Phase Between Active and Alert Lines – Warning sign that labor may be prolonged – If in hospital, perform amniotomy (ARM) and observe carefully – Consider transfer to higher level of health care where emergency obstetrical care can be provided for further care

15. Abnormal Labor: Prolonged Active Phase At the ACTION Line – Assess woman and determine possible reasons for lack of progress and further management plan – Consultation and transfer of care to health facility that can provide emergency obstetrical care, if requiring more intervention

16. Dystocia Abnormal progress in labor Cannot be diagnosed until after latent phase of labor completed Significance – Associated with maternal morbidity including: Dehydration, sepsis, uterine rupture, vesicovaginal fistulae, postpartum hemorrhage – Contributes to neonatal morbidity & mortality (sepsis and asphyxia) – Contributing factor in maternal mortality

17. Dystocia - 2 Cannot be diagnosed until patient in active labor Causes – Mechanical dystocia – Associated with inappropriate induction of labor with unripe cervix – Cephlopelvic disproportion – Exacerbated by endemic malnutrition or pregnancy before physical maturity

18. Dystocia - Etiology Powers – Uterine contractions hypotonic or uncoordinated – Ineffective maternal expulsive effort Passage – Fetal position, attitude, size, or abnormalities Passenger – Structure of bony pelvis or soft tissue factors Psychology – Fear, maternal anxiety and pain, lack of companion, unsupportive environment

19. Powers Assess contractions by abdominal palpation Adequate contractions are: – Regular – Progressive leading to cervical dilatation – Frequent – every 2 -3 minutes – Duration – 45 – 60 seconds in length

20. Passage Assess passage clinically in regards to: – Prominent spines or sacrum – Narrow pubic arch – A space-occupying pelvic mass

21. Passenger Assess fetal size and position Inadequate powers may result in malposition of a normal size fetus – Ascynclitic – Deflexed head

22. Psychology Assess maternal psychological needs – Sources of stress include: Companionship Provide information about progress of labor to patient and involve in decision making Offer pain relief Encourage ambulation and position changes

23. Preventing Dystocia Accurate diagnosis of Active Labor – Begin managing labor when in active labor (ie. cervix > 4 cm dilated) – Resist urge to intervene when in Latent labor Management of Prolonged Latent Phase – Avoid admission until in Active Labor – Offer assessment and care in non-laboring area of hospital – Establish plan to meet patient’s needs

24. Preventing Dystocia (2) Prepared childbirth – creates a positive experience for the woman. Other benefits: – Less apprehension – Lower pain scores and less analgesia required – No adverse effects on labor – Reduction in amount of anesthetic required – For nulliparous women – more rapid progress in labor

25. Preventing Dystocia (3) Birthing companion and continuous emotional supportive includes: – Emotional support from continuous presence and reassurance of supportive family members, relatives or friends – Information about labor progress and advice regarding coping techniques – Advocacy – Comfort measures such as massage, touch, warm showers or baths, adequate fluid intake

26. Preventing Dystocia (4) Ambulation and positions in labor – Encourage women to be in comfortable positions – Upright position reduces pain experienced by woman – Provide supportive equipment such as chairs, birthing balls and birthing stools

27. Active Management of Labor Rigorous diagnosis of active labor Close surveillence of labor progress with partograph, intervene when appropriate Continuous support in labor Careful use of amniotomy Cautious use of oxytocin augmentation Appropriate use of operative vaginal delivery If CPD – Cesarean Section

28. Oxytocin Augmentation Ensure appropriate use of analgesia, hydration, rest and amniotomy first Encourage to keep bladder emptied Use oxytocin if progress of labor <0.5 cm/hr over 4 hours or arrest of descent in second stage over 1 hour of pushing

29. Second stage of Labor If prolonged may require operative delivery – Vacuum assisted vaginal delivery – Cesarean Section

30. Conclusion A woman in labor requires a supportive environment with a skilled birth attendant who can provide good clinical and empathetic care. Proper management of labor includes accurate diagnosis of labor, correct use of partograph, and appropriate intervention when problems arise. Good clinical management of labor and delivery prevents maternal and neonatal morbidity and mortality due to obstructed labor.