1. Labour Management
Neil Vanes
StR5 Obs and Gynae

2. Labour & Monitoring & Management
Learning Aims:
What is normal labour?
What is abnormal labour?
How is abnormal labour managed?
How is abnormal labour monitored?

3. Early take home points IMPOSSIBLE to cover all abnormality in one!!
Specialist Training takes 7-10yrs
Don’t think that majority of labours are abnormal, they are NOT
JUMP IN – don’t be shy

4. What is normal labour?
Spontaneous onset of contractions at term with a
normally grown fetus in
cephalic presentation
progressing to
full dilatation
with a
spontaneous vaginal delivery
of a
live infant

5. Course of Labour

8. What is abnormal labour?
Prolonged rupture of membranes
Prolonged pregnancy with induction of labour
Intra-uterine growth restriction / macrosomia
Abnormal presentation
Failure to progress
Operative vaginal delivery
Retained Placenta

9. ABBREVIATIONS
PROM: prelabour rupture of membranes, sometimes referred to as premature rupture of membranes. Can also be used to mean prolonged rupture of membranes
PPROM: preterm prelabour rupture of membranes, ie before 37 weeks
SROM: spontaneous rupture of membranes
ROM: rupture of membranes

10. Prelabour / prolonged rupture of membranes (PROM)
Definition:
spontaneous rupture of membranes (SROM) at term without the onset of spontaneous contractions
Prelabour rupture of the membranes (PROM) occurs in 6-19% of term pregnancies.

11. Risks of PROM at term maternal/neonatal infection prolapsed cord.
Epidemiological data on time interval from PROM to spontaneous labour suggests that most (86%) women go into spontaneous labour within 24hrs of rupturing their membranes.
The rate of spontaneous labour after this is about 5% per day.
As the time between the rupture of the membranes and the onset of labour increases, so do
the risks of maternal and fetal infection.
Induction of labour reduces these risks.

12. CHOICES for PROM immediate induction of labour
expectant management (should not exceed 96 hours)

13. Prolonged pregnancy with induction of labour
Term
between 37 completed weeks and 42 weeks
Prolonged pregnancy
after 42 weeks
Risks:
Stillbirth
Meconium liquor / aspiration

14. Induction of Labour Methods
Prostaglandins – ripen cervix and prime uterus for contractions
Artificial rupture of membranes
Syntocinon infusion

15. Failure to Progress Latent phase of labour: Active phase of labour:
effacement + 0-3cm dilation
Active phase of labour:
3-10cm dilation
cm / hr (primip vs multip)
Transition
2nd stage of labour:
full dilation (10cm) to delivery
3rd stage of labour:
delivery of placenta

16. Course of Labour

18. Failure to Progress Assess progress in labour by
PA (abdominal palpation)
VE (vaginal examination)
Engagement / station of fetal head
PA:
engagement (fifths palpable: 5/5 to 0/5)
VE:
descent of fetal head (station: -3 to +3)
Fetal position: LOA, LOT, DOP, ROP, ROT, ROA

19. Occipito-posterior
Occipito-anterior

21. How is abnormal labour managed?
Power
Passage
Passenger

22. How is abnormal labour managed?
Power: Effective contractions
Maternal factors: e.g. hydration
Membranes intact?
Augment contractions e.g. syntocinon

23. How is abnormal labour managed?
Passenger
Fetal size
Fetal position (OA vs OP)
Encourage OA position (all fours, upright)
Epidural

24. How is abnormal labour managed?
Passage
Assess pelvis: Cephalo-pelvic disportion (CPD)
Retrospective diagnosis:
normal size baby in occipito-posterior position
big baby in occipito-anterior position
Promote anterior occipito position

25. Occipito – anterior position

26. How is abnormal labour monitored?
Maternal monitoring
Partogram
Fetal monitoring
CTG

27. Abnormal presentation
Breech
Other: transverse / oblique lie
(hand, cord presenting / prolapsing)
ECV vs elective C/S

28. External Cephalic Version
Procedure for turning the baby

29. Operative vaginal delivery
Correct Placement of Kiwi

30. Cardio Toco Graph (CTG)

31. A: Fetal heartbeat;
B: Indicator showing movements felt by mother (caused by pressing a button);
C: Fetal movement;
D: Uterine contractions

32. Classification of FHR trace features
Baseline (bpm)
Variability (bpm)
Decelerations
Accelerations
Reassuring
110–160
≥ 5
None
Present
Non- reassuring
100–109
161–180
< 5 for 40–90 minutes
Typical variable
decelerations with
over 50% of contractions,
occurring for over 90 minutes
Single prolonged deceleration
for up to 3 minutes
The absence
of accelerations
with otherwise
normal trace is
of uncertain
significance
Abnormal
< 100
> 180
Sinusoidal
pattern
≥ 10 minutes
< 5 for
90 minutes
Either atypical variable
decelerations with over
50% of contractions or
late decelerations, both
for over 30 minutes
Single prolonged
deceleration for more
than 3 minutes

33. Fetal Blood Sampling

34. Definition of normal, suspicious and pathological FHR traces
Category
Definition
Normal
An FHR trace in which all four features are classified as reassuring
Suspicious
An FHR trace with one feature classified as non-reassuring and
the remaining features classified as reassuring
Pathological
An FHR trace with two or more features classified as non-reassuring
or one or more classified as abnormal
Classifications of CTG’S
1) Normal: Implies fetal well-being
2) Suspicious: Indicates continued observation /additional tests
3) Pathological: Mandatory Action.

35. Fetal Blood Sampling

36. Fetal Blood Sampling For pathological trace
Must be at least 3-4 cm dilated
pH>7.25: reassuring, but if CTG deteriorates then repeat
pH: : repeat in 30 minutes or deliver
pH<7.20: deliver

37. Caesarean Section
A Caesarean section is a surgical procedure in which an incisions is made in the uterus to deliver one or more babies
The first modern Caesarean section was performed by German gynaecologist Ferdinand Adolf Kehrer in 1881.

38. THANK YOU!