1. Obstructed Labour and The Partogram
ESMOE

2. Causes of Neonatal deaths in SA Saving Babies (2010-2011)
Prematurity
Asphyxia

3. Show PPIP data for the most common causes of perinatal death in term babies – intrapartum asphyxia

4. Lists the most common avoidable factors in intrapartum asphyxia (Saving Babies) – problems with monitoring

5. MATERNAL DEATHS FROM OBSTETRIC HAEMORRHAGE
Saving Mothers report :
684 deaths (15.8%) from haemorrhage

6. Causal sub-categories of Obstetric Haemorrhagen %
Bleeding at/after C section
221
32.3
Abruptio placenta
108
16.1
Ruptured uterus
103
15.1
“other PPH” 84
12.3
Retained &/or adherent placenta 62
9.1
Atonic uterus 50
7.3
Vaginal/cervical trauma 25
3.7
Placenta praevia 16
2.3
“other APH” 8
1.2
Inverted uterus 5
0.7
TOTAL
684
100

7. Aims To understand the use of the partogram
To recognise slow progress in labour and manage it appropriately
To practise the skills needed to respond to a woman in obstructed labour 7

8. Partogram A graphical record of progress in labour
Should be used in every labour at all facilities doing deliveries
Start using once the woman is in labour 8

10. SA DoH Partogram

11. Patient information: Fetal heart rate:
Fill out name, gravidity, parity, hospital number,
date, time of admission and time
of membrane rupture. 1st risk assessment
Fetal heart rate:
Record every half hour.

12. Amniotic Fluid
Record the colour of amniotic fluid at every vaginal examination:
I: membranes intact;
C: membranes ruptured, clear fluid;
M: meconium-stained fluid;
B: blood-stained fluid.

13. Moulding 0 or -: sutures separate 1+: sutures apposed
2+: sutures overlapped but reducible
3+: sutures overlapped and not reducible

15. Plotting Dilatation
Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the alert line of the partogram at 4 cm.
Alert line: A line starting at 4 cm of cervical dilatation and extended to the point of expected full dilatation at the rate of 1 cm per hour or faster.
Action line: Parallel and 2 hours to the right of the alert line.

16. Descent Descent assessed by abdominal palpation:
Refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis
recorded in fifths at every vaginal examination.
At 0/5 there is no head palpable above
the symphysis pubis.
Reported as head above brim (HAB)

17. Time Hours: Refers to the time elapsed since
onset of active phase of labour.
Please note change in time scale when
transferring
from latent to active phase
Time: Record actual time in hours and when entering always extend the timeline.

18. Medication Oxytocin: Record the amount of oxytocin
per volume IV fluids in drops per minute
(using a 15 drops/ml administration set)
every 30 minutes when used.
Drugs given: Record any additional drugs given.

19. Pulse: Record every 30 minutes and mark with a dot (●).
Blood pressure: Record every 4 hours and mark
with arrows (▲= systolic and▼ = diastolic).
Temperature: Record every 2 hours.
Urine: Record the presence of proteins, ketones
and measure the volume every time urine
is passed.

20. Contractions Chart every half hour
Palpate the number of contractions in 10 minutes – fill in the appropriate no of blocks
Note their duration in seconds
Time is used as a surrogate for strength
Less than 20 seconds:
Between 20 and 40 seconds:
More than 40 seconds:

21. TRANSFER FROM LATENT TO ACTIVE PHASE IS INDICATED BY AN ARROW THIS ALSO INDICATES A NEW TIME SCALE

22. Labour A correct diagnosis of labour has to be made
before entering on the partogram
Decide whether in latent or active phase of
labour
Latent phase characterised by:
Progressive shortening and dilatation of the cervix → 3 cm
Active phase:
4cm (or more) dilated – plot on the Alert Line on the active phase of the partogram
Regular, painful and progressive contractions 22

23. Plotting Latent Phase If uncertain do not enter on partogram
Once latent phase confirmed enter
Always plot on the extreme left hand side
Prolonged latent phase needs an intervention

24. Latent Phase Observations
BP, pulse, temp
Vaginal examination
All 4 hourly
Urine testing prn
FHR – 2 hourly
Contractions (10 mins) and HAB ½ hourly

25. Latent Phase
If the contraction pattern or the patient’s condition changes a PV should be performed. This assessment should be noted in the file

26. Active Phase of Labour Regular contractions
Starts with a cervical dilatation of 4cm or more
Dilatation of cervix – at least 1cm per hour
Descent of presenting part – decrease in the amount of head above brim 26

27. Observations in Active Phase
Contractions - ½ hourly
BP and pulse – hourly
Head above brim – 2 hourly
PV – 2 hourly
Temp – 4 hourly
Urine (output & dipstix) – prn

28. FHR in Active Phase Low risk
FH ½ hrly with doptone (after contraction)
Auscultation acceptable
High risk
Ideally CTG
½ hrly doptone acceptable

29. Active Phase
All women should be encouraged to have an accompanying person All women should be offered pain relief

30. Slow Progress in Labour? Evaluate The 4 P’s
Patient
Pain, hydration, bladder
Powers
Inadequate contractions (dysfunctional labour)
Passenger
Abnormal presentation or position
Fetal abnormality eg hydrocephalus
Passage
Pelvis too small for baby (cephalopelvic disproportion – CPD) 30

31. Powers - Uterine Contractions
Slow progress often due to inadequate contractions in a primigravida
Restore normal progress by rupturing membranes and giving oxytocin by iv infusion according to local regime
Reassess in 2 hours
If no further progress deliver by CS 31

32. Remember!
Slow progress may be due to any of the 4Ps-patient, power, passenger, passage
Secondary arrest in a multipara may be the first sign of CPD
Augmentation with oxytocin may be dangerous and cause rupture of uterus 32

33. Monitoring in 2nd Stage Midwife constantly with patient
FH after every 2nd contraction
Check descent & progress every 15 minutes
Record all of the above
CTGs should be properly identified and kept

34. Slow progress in the second stage
Duration of 2nd stage timed from onset of desire to bear down/push
Primigravidas – 45 minutes
Multigravidas – 30 minutes 34

35. Management of Slow Progress in Second Stage
If fetal head palpable above brim deliver by CS
With up to 1/5 fetal head palpable above brim consider assisted delivery
At a CHC, if 2nd stage is prolonged: REFER if assisted delivery not an option
Ventouse preferred to forceps, and symphysiotomy may not be practised in some countries by law ie Ghana 35

36. If slow progress becomes no progress labour is obstructed
If slow progress becomes no progress labour is obstructed. It is better to make a wrong decision than to do nothing (wait and see) 36

37. Obstructed Labour – The Reality!37

38. Obstructed Labour – Clinical Features
Maternal: dehydration, tachycardia, fever, poor urine output, sepsis, ruptured uterus
Fetal: abnormal or absent FH 38

39. Obstructed Labour – Immediate Care
Assessment
I/V fluids
Antibiotics
Delivery by appropriate method 39

40. Obstructed Labour – Delivery Options
Fetus alive  CS or assisted delivery
Fetus dead  ventouse or CS
Ruptured uterus  laparotomy  repair or hysterectomy 40

41. ?

42. Recap Use of the partogram National DoH Partogram
Saving Mother & Babies recommendation
Managing problems identified with use of partogram
Dangers of syntocinon use
Preventing obstructed labour
Recognising obstructed labour
Complications of obstructed labour
Management of obstructed labour

43. Umbilical Cord Clamping (UCC)
Active management of the 3rd stage Oxytocic Early cord clamping Controlled cord traction Only 1 is effective – the oxytocic

44. When Should You Clamp the Cord?
1 – 3 minutes after delivery

45. Why?
At birth the baby is born with a “fetal circulation” The first breath opens up the lungs The neonate now has a vascular space with no blood Delayed cord clamping allows about a 20 – 30% increase in the blood volume This results in smooth transition

46. Benefits of Delayed Cord Clamping for Term Infants
Higher early haemoglobin concentration Increased iron reserves up to 6 months after birth No difference in PPH rates Higher birth weight No statistically significant increase in jaundice or polycythemia

47. Benefits of Delayed Cord Clamping for Preterm Infants (< 37 wks)
Providing additional placental blood to the preterm baby by delaying cord clamping by 30–120 seconds resulted in
Fewer babies needing transfusions for anemia Better circulatory stability
Reduced risk of intraventricular hemorrhage (all grades)
Reduced risk of necrotizing enterocolitis
Reduced late-onset sepsis

48. Benefits of DCC for Very Preterm Infants (< 30 wks)
2–3-fold reduction in intraventricular hemorrhage
Reduced need for blood transfusions
Greater mean blood pressures in the first hours of life
No difference in Apgar scores at 5 minutes/body temperature
Just short of statistical significance for halving of mortality with DCC in these infants

49. Early Cord Clamping – Proven Adverse Effects
Variable degree of hypovolemia
Severe hypovolemia when preceded by intrapartum cord compression
Hypoxia
Sudden decrease in preload to the heart

50. Adverse Events – Cont:
Increases afterload dramatically by obstructing the umbilical arteries, thus increasing peripheral vascular resistance Fall in cerebral circulation Fall in cardiac output Bradycardia

51. So – Do Not Cut the Cord Early!!
Remember – the 1st minute activities are unchanged. Give the baby to the mother - promote skin-to-skin Position of the baby does not affect the transfusion volume

52. Thank you Any questions?
End of Lecture
Thank you
Any questions?

53. Enter the following information onto your partogram
Partogram - Case 1
Enter the following information onto your partogram

54. Demographics
Kerry, a 20 year old primigravida, presented to the labour ward with a 2 hour history of contractions at 38+ weeks gestation.
She was booked and her antenatal course had been uneventful

55. 09:00
Vitals: BP 120/80 mmHg, pulse 90/min and temperature 37°C
Contractions: 2/10 minutes lasting 15 seconds
Palpation: longitudinal lie, Vertex, 5/5 HAB
FHR: 144
PV: Cx 2 cm dilated

56. Action 1st question? Is she in latent or active phase of labour?
So?
Enter her on the left of the partogram
And?
Enter and extend the timeline

57. Entering Of the information presented what must be entered first?
Cx 2 cm dlated
What next?
The time
And then?
Extend the timeline
And then enter the rest of the information

59. Next Exam @ 13:00 Contractions: 3 in 10 minutes lasting 35 seconds
HAB: 3/5
FHR: 144
10:00 – clear liquor draining
Vitals: BP 120/70, pulse 88/min, temp 37°C
PV: Cx 4cm dilated

60. Action 1st question? Is she in active or latent phase? Active phase
So?
Transfer to Alert line
Then?
Enter new time scale and extend
Draw arrow to indicate transfer

61. And then enter and extend the new time scale
Please Remember
When entering on the active phase side of the partogram first plot the cervical dilation on the alert line
And then enter and extend the new time scale

63. Further Progress @ 15:00 FHR 146/min Liquor clear Cx 8cm dilated
HAB 2/5
Contractions 3/10 min lasting 50 seconds
BP 120/70 mmHg, Pulse 85/min, 100 ml urine
Enter onto partogram

64. Remember! First to enter the cervical dilation
Check that the time scale is correct

66. Interpretation and Action?
Comment on progress
Making good progress because staying to the left of the alert line, mother in good condition and baby has clear liquor and no caput or moulding.
Any concerns?
Of slight concern is the fact that the patient is primigravid and still has 2/5 above brim
Reassess in 2hrs – should be fully dilated

67. Enter the following information onto your partogram.
Partogram – Case 2
Enter the following information onto your partogram.
Julia is a 19 year old primigravida at term who has been experiencing contractions for 2 hours. Her antenatal course was uneventful.

68. Plot The Following TIME Cx cm Contrct FHR LIQUOR HAB MOULD CAPUT 06:005
3/10 35s
140
INTACT
4/5
08:00
146
CLEAR
3/5
10:00
3/10 25s +

69. 1st Question
Is she in active or latent phase? Active phase So? Enter Cx dilatation on the alert line Enter and extend the time line Should you enter anything on the latent phase side? No

71. Interpretation & Action?
Comment on partogram
No progress (Cx constant, no descent)
What action should be taken?
Examine the 4 P’s
Inadequate powers
Management?
Syntocinon and analgesia
Follow up?
Should be progressing well in 2 hours
If not? →C/S

72. If Julia had been examined 4 hourly her chart would have looked like the next slide and the same diagnosis and intervention made 6 hours earlier

74. Case 3
Helen, a 34 year old G4P3 at term has been in labour at home for 6 hrs
Maternal vital signs remain normal

75. Enter The Following Information onto Your Partogram
TIME Cx
Contract
FHR
Liquor
HAB M C
10:00 4
3/10 35s
150
Clear
3/5 +
14:00 6
4/10 45s
156
Blood stained ++
16:00
164
Meconium
+++

77. Interpretation & Action?
Are there any problems?
CPD – why?
No cx dilatation, no descent, good contractions, moulding 3+
Fetal distress – why?
Tachycardia, 3+ moulding, (meconium)
Treatment?
Intra-uterine resus & C/S (+?BTL)

78. Case 4
Maria is a 25 year old G2 P1 who had an assisted delivery of a 3.4 kg baby 3 years ago. She booked early and her antenatal course was uneventful She presented to the labour ward with a 2 hour history of contractions.

79. Enter The Following Information
Time Cx
Contractions FH
Liquor
HAB M C
08:00 4
3/10, 35s
142
3/5
10:00 6
4/10, 50s
145 1+ +
12:00
161 2+

81. Interpretation & Action
Are there any problems? Yes – crossed Alert Line Was there a problem at 10:00? Yes – multip progressing on Alert line What should be done now? C/S What about augmentation of labour? No – risk of uterine rupture in a multip

82. What abnormalities can we diagnose on the partogram?

83. Failure to Progress Poor uterine action
No Cx dilatation or descent BUT healthy mother & baby – weak contractions
2. CPD
As above but with unhealthy baby ± ill mother – strong contractions or 2° arrest
3. Incorrectly charted
Not transferred to the alert line
Latent phase entered on active side

84. Late +/or abnormal decelerations
Fetal Distress
Tachycardia
Late +/or abnormal decelerations
Loss of variability
3+ moulding
(Meconium)

85. Decreased urine output
Maternal Distress
Tachycardia
Decreased urine output
↑ ketonuria
Pyrexia

86. Poor Management