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?