1. Partogram and Obstructed Labour H
Partogram and Obstructed Labour H. Gee MD, FRCOG Consultant Obstetrician

2. When is a Woman in Labour?

3. Good Management of Labour

4. First StagePatterns of Aberrance
Three types
These are NOT diagnoses
SIGNS
Only Secondary Arrest correlates with recognised pathology
CPD about 30-40% What of the rest
Some will respond to augmentation overcome CPD
improved rotation/flexion
PDL Powers
Abnormal mechanisms/de-flexion
???? cervix

5. Patterns of Aberrance Prolonged Latent Phase
Slow cervical dilatation before Active Phase established
20 hrs Nullips & 14 hrs Multips
Primary Dysfunctional Labour
Progress< 1 cm/hr before Active Phase slope established
Incidence: Nullips 26%, Multips 8%
Secondary Arrest
Cessation after normal active phase dilatation
Incidence: Nullips 6%, Multips 2%
Classical definitions
A lot of speculation about pathology causing these

6. PARTOGRAM- EAST AFRICA’S GIFT TO THE WORLD
Invented in Africa 1960’s
Identify delay
Identify increasing risk
To determine place of delivery
No comparative or controlled trials
Common sense value recognised

7. Active Phase Cervicograms - Philpott & Castle 10 8 6 4 2
Alert Line
Action Line
Cervical Dilatation (cms,)
Time (hrs.)
Philpott
Rhodesia
? Ethnic differences - some evidence to say so

8. WHO Partograph Study
Reduced incidence of prolonged labour (8.3% vs 4.5%)
Decreased need for augmentation (32% vs 13%)
Increased spont vag del (74% vs 78%)
Decreased caesarean section (9.8% vs 6.8%) *
Effect of fixed management policy - not so much the Partogram
Reduced prolonged labour
Decreased oxytocin use CORRECT D OF LABOUR
Increased spont. Delivery
CS improvement does not reach sta. Sig.
Lancet 1994
343; (Nullips)
* not Statistically Sig

9. Why not done? Result from Malawi audit

10. Partograph assessment by progress of labour and augmentation, by type of facility Results from Malawi audit

11. Second Stage
Descent
Rotation
Duration
Passive
Active(Pushing)

12. Current situation Midwife tells you CS needed Problems Is she right?
Do you understand the problem & implications.
Are there alternatives?
e.g. forceps/vacuum in second stage

13. New situation You are team leader because of this course When called
You assess patient
Power/passages /passenger
You improve care by whole team

14. Parity & Obstruction
Nulliparous
Inertia
Multiparous
Uterine Rupture

15. COMPONENTS OF LABOUR The powers The passages The passenger
Uterine contractions
The passages
bony pelvis, and soft tissues
The passenger
fetus

16. Powers Essential for good progress Assessed by Palpation
Cervical Dilatation
Flexion
Rotation
Assessed by Palpation
Frequency 3-5 in 10 min.
Augmented by Oxytocin & Amniotomy

17. The Passages Bony pelvis Absolute cephalo-pelvic disproportion
Kyphosis, Scoliosis, poliomyelitis, maternal dwarfism, ricketts, pelvic fracture.
Soft tissue
fibroids, ovarian tumour, pelvic kidney, fat, cervical stenosis, cervical cancer, vaginal\vulval atresia, vaginal septum.

18. The Passages Disproportion Head Not Engaged CS essential PPH
> 4/5 Palpable abdominally
VE: high head, caput+++, moulding+++
CS essential
PPH
Risk increased in Prolonged/Obstructed labour

19. The Passenger-1 Large Fetus Idiopathic Pathologic macrosomia,
Increasing Parity
Pathologic macrosomia,
diabetes
Fetal abnormalities
hydrocephalus
conjoined twins
hydrops fetalis

20. The Passenger-2 Malposition Malpresentation Occipito-Posterior
Mento-Posterior
Malpresentation
compound presentations
shoulder
brow
face

21. Signs of Obstruction Maternal Fetal Tachycardia Pyrexia Ketosis
Dehydration
Fetal
Fetal heart rate abnormalities

22. Treatment General Specific Re-hydration
Anti-biotics (if infection suspected)
Specific
According to diagnosis
Caesarean section

23. Caesarean Section in Obstruction
Cesarean Section Problems
Impacted head – dis-impact before start
PPH
IV sytno/ergometrine/misoprostol ready
Bladder Injury
Leave catheter in for 10 days if blood stained
Infection
IV antibiotics

24. Post delivery Reflective practise- team leader
Critical incident review
WHY Poor Outcome?
NO TRAINING
NO EQUIPTMENT
POOR COMMUNICATION
MATERNAL HEALTH VERY POOR

25. Improve Partogram Use 4 hourly ward rounds/teaching
Critical incident review
What was wrong?
Audit
Change
Re-audit