Partogram and management of 1st and 2nd stages of labor

Kufa University

By Ali S. Mayali

• Normal labor is a process by which regular uterinecontractions causes progressive effacement and dilatation ofthe cervix and the final result is the delivery of the fetus andthe placenta.

Management of normal labor

• History.• Examination:

• General examination.• Abdominal examination.• Vaginal examination.

• Fetal assessment:• Partogram.

• Management during 1st stage.• Management during 2nd stage.

The History

• Previous births and size of previous babies. • Previous caesarean section. Onset, frequency, duration and

perception of strength of the contractions. • Whether membranes have ruptured and, if so, color and amount of

amniotic fluid lost. Presence of abnormal vaginal discharge or bleeding.

• Recent activity of the fetus (fetal movement). • Medical or obstetric issues of note (e.g. diabetes, hypertension, fetal

growth restriction [FGR]).

General examination

• General look at the patient.

• Temperature.

• Pulse.

• Blood pressure.

• BMI.

• Urinalysis.

Abdominal examination.

• inspection for scars indicating previous surgery.

• determine the lie of the fetus (longitudinal, transverse or oblique) and the nature of the presenting part (cephalic or breech).

• If it is a cephalic presentation, the degree of engagement must be determined in terms of fifths palpable abdominally.

• If there is any doubt as to the presentation or if the head is high, an ultrasound scan should be performed to confirm the presenting part or the reason for the high head (e.g. OP position, deflexed head, placenta previa, fibroid, etc.…).

• Abdominal examination also includes an assessment of the contractions.

Vaginal examination.

• The purpose and technique of vaginal examination is explained to the woman and her consent must be obtained.

• The length of the cervix at 36 weeks’ gestation is about 3 cm. It gradually shortens by the process of effacement and may still be uneffaced in early labor. The dilatation is estimated digitally in centimeters. At about 4 cm of dilatation, the cervix should be fully effaced. Providing the cervix is at least 4 cm dilated, it should be possible to determine both the position and the station of the presenting part. When no cervix can be felt, this means the cervix is fully dilated (10 cm).

Vaginal examination.

• A vaginal examination also allows assessment of the fetal head position, station, attitude and the presence of caput or moulding.

• In normal labour, the vertex will be presenting and the position can be determined by locating the occiput. The occiput is identified by feeling for the triangular posterior fontanelle and the three suture lines.

• Failure to feel the posterior fontanelle may be because the head is deflexed (abnormal attitude), the occiput is posterior (malposition) or there is so much caput and moulding that the sutures cannot be felt. All of these indicate the possibility of a prolonged labour or a degree of mechanical obstruction.

Vaginal examination.

• Relating the leading part of the head to the ischial spines will give an estimation of the station.

• This vaginal assessment of station should always be taken together with assessment of the degree of engagement by abdominal palpation. If the head is fully engaged (zero-fifth palpable) at or below the ischial spines (0 to +1 cm or more) and the occiput is anterior (OA), the outlook is favorable for vaginal delivery.

• The condition of the membranes should also be noted.

Fetal assessment in labour.

• With each contraction, placental blood flow and oxygen transfer are temporarily interrupted and a fetus that is compromised before labour starts will become increasingly so.

• Hypoxia and acidosis cause a characteristic change in the fetal heart rate (FHR) pattern, which can be detected by auscultation and the CTG.

• Meconium (fetal stool) is often passed by a healthy fetus at or after term as a result of maturation of the gastrointestinal tract; However, it may also be expelled from a fetus exposed to marked intrauterine hypoxia or acidosis; in this scenario, it is often thicker and much brighter green in color.

Fetal assessment in labour.

• The FHR should be auscultated. It should be listened to for at least 1 minute immediately after a contraction. This should be repeated every 15 minutes during the first stage of labour and at least every 5 minutes in the second stage.

Indications for continuous EFM• Significant meconium staining of the amniotic fluid.

• Abnormal FHR detected by intermittent auscultation.

• Maternal pyrexia (temperature ≥38.0°C or ≥37.5°C on two occasions).

• Fresh vaginal bleeding.

• Augmentation of contractions with an oxytocin infusion.

• Maternal request.

The partogram

• diagrammatic record of the events of labour.

• Monitor the progress of labour, maternal and fetal wellbeing

• Early detection and management of labour abnormalities.

- Membrane intact record as “I” -Membrane rupture:

- a) liquor clear record as “C” - b) meconium stained liquor “M” - c) liquor absent record as “A”

The partogram

The alert line:

• Drawn from 3 cm dilatation ( at rate of dilatation of 1 cm/hour).

• Represents the rate of dilatation of the slowest 10 % of labours in primigravidae.

Crossing the alert line suggests that the patient should be transferred to a hospital for extra care.

The action line:

• parallel and 4 hours to the right of the alert line.

crossing the action line suggests the need for intervention(e.g., artificial rupture of the membranes, administration of oxytocic.

• If labour progress well plotting of cervical dilatation should always remain to the left of alert line.

• If it cross to right of action line this warns that labour may be prolonged.

Plot dilatation as “X” Plot descent as “O”

Each square represent 1 contraction felt in 10 minutes.

Good or bad progress?

Key management principles of 1st labor

• First stage of labour is the interval from diagnosis of labour to full dilatation of the cervix.

• One-to-one midwifery care should be provided. • Additional emotional support from a birth partner should be encouraged. • Obstetric and anesthetic care should be available as required. • Maternal and fetal wellbeing should be monitored. • Vaginal examinations are performed 4 hourly or as clinically indicated. • Progress of labour is monitored using a partogram.• Appropriate pain relief should be provided consistent with the woman’s

wishes. • Ensure adequate hydration and light diet to prevent ketosis.

Management of second stage labor

• Onset of 2nd stage:• Urge to push.• Full cervical dilatation (check by vaginal exam).• Urge to defecate and urinate.• More prolonged contractions.

• Preparation for delivery:• Women should be discouraged from lying supine, or semi-supine, and should

adopt any other position that they find comfortable. • Empty bladder.• Light diet.• Epidural analgesia (pushing is usually delayed if epidural is in situ).

Management of second stage labor

• After internal rotation of head, further descent occurs, until the sub-occiput lies underneath the pubic arch.

• At this stage the max diameter of head stretches the valval outlet without any recession of head even after contraction is over-It is called CROWNING.

• This indicates that it has passed through the pelvic floor.

• Episiotomy may be needed (It will only accelerate the birth if the head has passed through the pelvic floor, so should not be performed too early).

• Effective analgesia is required, and this will usually be with infiltration of local anesthetic if the woman does not have an epidural.

Management of second stage labor

• To aid delivery of the shoulders, there should be gentle traction on the head downwards and forwards until the anterior shoulder appears beneath the pubis. The head is then lifted gradually until the posterior shoulder appears over the perineum and the baby is then swept upwards to deliver the body and legs.

• If the infant is large and traction is necessary to deliver the body, it should be applied to the shoulders only, and not to the head.

Immediate care of the neonate

• After the baby is born, it lies between the mother’s legs or is delivered directly on to the maternal abdomen.

• Cord clamping (There is no need for immediate clamping of the cord).

• Oropharyngeal suction should only be applied if really necessary.

• After clamping and cutting the cord, the baby should have an Apgar score calculated at 1 minute of age (normally 7).

• The baby should be dried and covered with a warm blanket or towel.

• breastfeeding should be encouraged.

• V. K

• General examination.

“Immediate skin-to-skin contact between mother and baby will help bonding, and promote the further release of oxytocin”

Kenny, L. C., & Myers, J. (n.d.). Obstetrics by ten teachers.