Partograms and assessment of progress in labour

1. Partograms and assessment of progress in labour Clare Tower MBChB PhD MRCOG Senior Registrar in Obstetrics and Gynaecology Subspecialty Trainee in Fetal and Maternal Medicine/ Clinical Lecturer St Mary’s Hospital, Manchester

2. Overview • Definition of labour • Normal labour • Diagnosis and assessment • Partograms • Abnormal labour • Cardiotocographs

3. Definition of labour • Regular painful contractions resulting in cervical dilatation • 3 stages • First • Second • Third

4. Stages of labour • First Stage • Up to fully dilated • Two phases • Second Stage • Full dilatation until delivery of the baby • Third stage • Delivery of the placenta

5. Latent phase Slow Contractions irregular Cervix: shortens (effaces) Softens Moves Dilates up to 3-4 cm First Stage of labour

6. Bishop’s score

7. Active phase Regular painful contractions Progressive cervical dilatation greater than 4 cm First Stage of labour (2)

8. Progress of normal labour • 5 Stages: • Descent • OT position • Widest part of head • Widest diam pelvis • Flexion • Stays OT • Chin to chest

9. Progress of normal labour (2) • Internal rotation • At pelvic floor • Turns to OA • Extension • Crowning • Facilitated by sacral curve • External rotation • Restitution • Shoulders

10. Duration of labour

11. Assessments in labour • The partogram • Labour record • Useful overview if completed properly • Can be used to aid diagnosis in abnormal labours • Visual representation of progress

12. Clinical info Fetal HR Liquor Dilation and descent Contractions Strength and timing Drugs Maternal Obs IV fluids Urinalysis

13. Assessment • History and review notes (handhelds) • Physical observations: temp, pulse, BP, urinalysis • Assess contractions: length, strength, frequency

14. Assessment • Abdominal palpation: • fundal height • lie • position • presentation • Station- relation to ischial spines • Vaginal loss • Show • Liquor • Blood loss

15. Assessment • Assessment of pain – need for pain relief • Fetal heart rate • Pinard or doppler • Listen for one minute after each contraction • Differentiate from maternal • Normal rate: 110-160 • Vaginal examination • If appears to be in labour • With consent

16. Pain relief • Gas and air • 50/50 mix of Nitrous oxide (N20) and oxygen • TENS • Transcutaneous electrical nerve stimulation • Opiates • Pethidine or diamorphine • Epidural • Most effective • Local anaesthetic + opiate mix

17. Normal labour

19. Length of second stage • Full dilatation until delivery • Can allow a ‘passive’ second stage for the head to descend • Epidurals • Total second stage less than 4 hours (NICE) • Pushing limited to 30 mins (multip) to 60mins (primip)

20. Abnormal patterns of labour • Partogram can be used to identify abnormal progress in labour • ‘3Ps’ – passenger, passages, powers • Deep transverse arrest • Primary dysfunctional labour

21. Obstructed labour Assessment: Powers Passenger Passages

22. CTG machine

23. Cardiotocograph CTG • Cardio = fetal heart rate • Toco = uterine activity: • Hence 2 monitors – • Abdominal pressure transducer • Doppler for fetal heart rate • Used to indicate fetal hypoxia • Poor!! – no reduction in the rate of intrapartum hypoxic injury/ Cerebral palsy since introduction in the 1980s • Increases rates of intervention • Even with the worse trace – 60% will be normoxic babies

24. Normal CTG Fetal heart rate Toco = uterine activity

25. Assessment of a CTG • DR C BRaVADO • DR = define risk • C= contractions • Timing and frequency • CTG cannot indicate strength • BRa = baseline rate • Normal 110-160 • beware changes in rate • Fetal heart increases in the presence of maternal tachycardia and increased temperature • Also increases with hypoxia and sepsis

26. DR C BRaVADO • V= Variability • Band width • Should be more than 5bpm • If reduced can indicate fetal sleep/ maternal opiate use • A= Accelerations • Increase in baseline of more than 15bpm for more than 15 seconds

27. DR C BRaVADO • D = Decelerations • = drops in fetal heart of more than 15bpm, lasting got more than 15 seconds • Time with contractions • Early – rare and benign • Late – pathological and indicate hypoxia • Variable – vary in timing and in pattern. Commonest and occur with cord compression • O = Overall • Make overall assessment taking into account all aspects

28. Variability = 20 bpm Baseline rate accelerations Contractions Irregular 1-2:10 Normal CTG No decelerations

29. Baseline rate = 170-180 Variability = 5 Late decelerations Abnormal CTG Contractions 4:10 No accelerations

30. Abnormal CTG

31. Abnormal CTG

32. Indications: Failure to progress Abnormal CTG Risks Maternal Vaginal trauma Perineal trauma Bleeding Fetal Bruising/ trauma Shoulder dystocia Instrumental Delivery

33. Caesarean Section • Elective - planned • Scheduled – maternal and fetal compromise not immediately life threatening • Deliver within 75 min • Audit of practice • Emergency: immediately life threatening • Deliver within 30 mins

34. Risks: Maternal Bleeding Thrombosis Bowel/ bladder damage Infection Anaesthesia Hysterectomy Next pregnancy Fetal lacerations 1-2% TTN (transient tachyapnoea of the new born) Indications Failure to progress/ abnormal CTG Caesarean Section

35. Any Questions?