Dysfunctional Labour & Partograph
- 1. Dysfunctional Labour and Partograph SALSO TEAM HOSPITAL UMUM SARAWAK
- 2. Correct diagnosis of labour • Regular contractions • Interval gradually shortens • Intensity of pain gradually increase • Duration of contraction increase • Progressive cervical effacement and dilatation • “Show’ may be present • (Progress of labour not stopped by sedation) • (Tightening not = contractions)
- 3. Importance: • Proper monitoring • Prevent unnecessary intervention - Artificial rupture of membranes - Wrong diagnosis of prolonged latent phase - Admission
- 4. “False” labour • Uterine contractions impalpable/ infrequent • Misdiagnosis unnessesary induction/ augmentation higher risk of failure with an increased risk of Caesarean section & chrioamnionitis
- 5. Definition • 1st Stage: – Start of labour Full dilatation of cervix • 2nd Stage: – Full dilatation delivery of baby • 3rd Stage: – Birth of baby delivery of placenta
- 6. Points to observe for… • Latent phase: Considered prolonged if it is greater than 8h in nullipara and 6h in multipara. • Active phase: On or at the left of an alert line • 2nd Stage: Need assessment if expulsive phase more than 30 minutes. (Max 1 hour for primips & ½ hour for multips) – Total 2 hours for nullips & 1 hour for multips • 3rd Stage : Retained placenta if not delivered by 30 minutes
- 7. Labour: Principles of management 1. Initial assessment 2. Diagnosis and intervention of abnormal labour 3. Close monitoring of fetal and maternal condition 4. Adequate pain relief 5. Adequate hydration 6. Emotional support/ supportive companion
- 8. Initial assessment • Define risk – Current & previous pregnancy – Medical/ surgical problems – Fetal condition • Degree of monitoring needed • Level of staff to manage the patient
- 9. Partograph • Diagrammatic representation of the progress of labour • “Story of a patient in labour” • Main components: • Progress of labour • Maternal condition • Fetal condition • Drugs given
- 11. Partograph Patient came in latent phase normal progress
- 12. Partograph Patient came in latent phase normal progress ( Showing station )
- 13. Partograph Patient came in active phase of labour normal/ good progress
- 14. Partograph Patient came in latent phase normal/good progress
- 15. Abnormal partograph (poor progress) • Latent phase > 8 hours • Cervical dilatation to the right of alert line • Cervical dilatation at or beyond action line
- 16. Partograph Dilatation < 4 cm despite 8 hours of regular contraction Patient with prolonged latent phase
- 17. Partograph Dilatation < 1cm/ hour in active phase due to ineffective uterine contractions < 3:10 < 40sec Patient came in active phase Primary dysfunctional labour
- 18. Partograph Patient came in active phase Secondary arrest
- 19. Secondary Arrest • Arrest of cervical dilatation and descent of presenting part despite good uterine contractions. Absolute CPD Relative CPD Big fetus /& small pelvis Fetal malposition
- 20. Partograph Intensity and frequency of contractions (Mild) (Moderate) (Severe)
- 22. Evidence of obstructed labour • Secondary arrest • Large caput • 3rd degree moulding • Poorly applied cervix to presenting part • Odematous cervix • Maternal/ fetal distress
- 23. Partograph • PARTOGRAM X 2 PAGES = PERINATAL MORTALITY • PARTOGRAM X 3 PAGES = MATERNAL MORTALITY
- 24. Factors affecting labour: 3 P’s - Power - Passage - Passenger - Position - Size - Attitude ( posture of fetus) ie. flexion/ deflexion/ extension
- 25. Power • Adequate effective contractions are needed for adequate progress of labour • Usually 3-4 in 10 min • Usually 40-60 s duration
- 26. Augmentation ( oxcytocin) • Correct dose and titration • To achieve “efficient “/”adequate” contraction. • Observe for hyperstimulation • Careful consideration in multipara and patients with previous scar • Max pitocin licensed for20 mu/min – Titrate 1, 2, 4,8, 12, 16,20, 24, 28, 32 ml/hr
- 27. Hyperstimulation • Prolonged contractions (> 2 mins) • Frequent contractions (<1:2) • Tetanic contractions (continuous) Intervention needed if associated with CTG changes
- 28. Passage • Clinical and X-ray pelvimetry – not used in modern obstetrics • Adequacy of pelvis can only be ascertain through labour and delivery • Passage may be adequate but might not be for a big baby
- 29. Passenger • Size of baby • Congenital abnormalities e.g. hydrocephalus, Anencephaly • Malposition : Incorrect positioning of the vertex (OP/ Deflexed head) • Malpresentation: Presence of presenting part other than vertex ( face, brow, breech, shoulder, compound)
- 30. FHR monitoring • In latent phase: * Low risk : Hourly * High risk : Every 15-30 min • • In active phase * Low risk: Every 30 min *High risk: Every 15 min
- 31. FHR monitoring • During second stage: * Low risk : Every 15 min *High risk: Every 5 min or after each contraction/pushing
- 32. FHR monitoring • Suspicious trace requires intervention or a referral to a senior person • Repeating trace with the hope it will return to normal is not advisable
- 33. FHR monitoring • In a patient in labour (contracting), fetal heart rate must be documented especially after a contraction. • Documentation of “fetal heart heard” is inadequate More on CTG in tomorrow’s lecture …
- 34. Adequate analgesia • Reduce pain perception & stress • “Tarik nafas” is not an analgesia at all • IM Pethidine 1-2mg/kg + Phenergan 0.5mg/kg 6 hourly • Entonox inhalation (50% O2 and 50% Nitrous oxide) at the start of contraction • Continuous epidural analgesia
- 35. Adequate hydration • Good hydration is important for satisfactory labour progress • Review hydration status regularly • Urine volume and urine ketones assessed • Allow low residual diet / oral fluids in labour except for high risk cases
- 36. Companionship / Doula • Provides reassurance to patient • Shown to: – Reduce analgesia requirements – Reduce Caesarean section & instrumental – Improve vaginal delivery rates
- 37. THANK YOU
- 39. Moulding Grade 0(No moulding), 1(sutures opposed),2(overlap;reducible), 3 (overlap; not reducible)
- 43. Caput succedaneum • (“Substitute head”) • Normal occurance due to pressure of cervix interrupting venous & lymphatic scalp drainage during labour. • Serous effusion between aponeurosis and periosteum • Disappear after few hours of birth