Chapter 17 Preparing for labour
17.1
The ‘powers of labour’
✿✿✿The muscles of the uterus are different from the muscles of the arms and legs. When the muscles which move the arms and legs contract, their fibres shorten. When these muscles relax, their fibres go back to the same length that they were before. But when the muscle of a mother’s uterus relaxes, its fibres don’t go back to the same length that they were before. They stay a little shorter (retracted). When they contract again, they become even shorter. This contraction and retrAction of the muscle of her uterus make four things happen:
Her lower
seg-ment forms.
Con-traction and retrAction happen more in the up-per segment (part) of her uterus than in the lower segment. They make the wall of the upper seg-ment thicker, and the wall of the lower segment thin-ner. Soon, a ring forms between the upper and lower segments. In a nor-mal labour you cannot feel this ring. If it is a very ob-vious ring, which you can feel through her abdominal wall, it is called Bandl’s ring and is a sign of obstructed labour (23.2 ).Sometimes, most of this thinning happens be-fore labour starts, or the thinning may begin dur-ing labour. When the lower segment has formed and become thinner, the presenting part of the fe-tus (the lowest part) can drop down into her pelvis. This is the lightening that some mothers feel in the last weeks of pregnancy (22.1).
✿✿✿✿
There is a lot to learn about delivering a baby safely. This chapter is mostly about how it happens. The next
chapter tells you what to do. When a mother goes into labour, her whole body shares in the work of delivering her baby,
so it is much more than the contractions of her uterus. Labour depends on three things. You can easily remember them,
because they all begin with ‘P’. They are: The ‘powers’ of labour, which are the contractions of her uterus. These push
the ‘passenger’, which is her baby through the ‘passages’ which are her birth canal, and especially her pelvis. When her
contractions, and her baby, and her pelvis are normal, her labour will be normal.
When a mother arrives in labour, welcome her. Make her feel confident by smiling and being friendly towards
her. Show her where she can take a wash before she comes into the labour ward. Make sure she understands the
impor-tance of washing her vulva and perineum thoroughly.
“The goats have no midwives, ●The sheep have no midwives, ●When the goat is pregnant she is safely delivered, ●When the sheep is pregnant, she is safely delivered, ●You, now you ar pregnant, will be safely delivered.” A Yoruba TBA’s song
Figure 17-2 HOW THE LOWER SEGMENT FORMS. The lower segment is the bottom part of the uterus.
But in 30% of human labours something goes seriously wrong!
July 4th 2011
Figure 17-3 EFFACEMENT AND DILATATION OF THE CER-VIX. A, When labour begins a mother’s cervix is 1-2 cm long, and is closed. B, effacement has started. Her cervix is being ‘taken up’ to be-come part of the lower segment of her uterus. C, effacement continues, the mucous plug is loosened, and there is a little bleeding (the ‘show’). D, her cervix is 1 cm dilated. E, her cervix is about 4 cm dilated. After Beischer NA and Mackay EV, ‘Obstetrics and the Newborn’, Fig. 39.1 WB Saunders, Permission requested.
Figure 17-6 EFFACEMENT COMES BEFORE DILATATION. Monitor effacement in percent, from 0% of its original length (about 4 cm) to 100% (no length). Monitor the dilatation of the cervix by meas-uring its diameter from 0 cm to 10 cm (fully dilated).
Figure 17-5 RECORDING CONTRACTIONS. The number of squares filled in records the number of contractions in 10 minutes. The shading shows the length of the contractions.
Her cervix
effaces.
In late pregnancy the con-tractions of her thicker upper segment pull the more relaxed lower segment upwards. This effaces her cervix (makes it shorter or ‘takes it up’). At 35 weeks her cervix is 4-5 cm long, but at term it is only 2-3 cm long. During the latent phase of the first stage of labour (see below) the con-tractions take up her cervix completely, so that it becomes com-pletely effaced (very thin). When you do a vaginal examination you can easily feel how effaced it is. Record-ing effacement is useful because it tells you how the beginning of labour is progressing . Progress in the latent phase is a very good indicator of what is likely to happen later in the active phase.
A mother’s cervix dilates
.
Contraction and retraction of the upper segment slowly pull her cervix open. They make it dilate (open). At term, before labour starts a mother’s cervix is often already 1 to 2 cm dilated. When it is 10 cm dilated, it is open enough for her baby to go through. It never dilates more than 10 cm. Ten centimetres is ‘fully dilated’, and is the end of the first stage of labour, and the beginning of the second stage (18.3).■MONITORING THE CERVIX. As birth approaches, a mother’s cervix ‘ripens and becomes favourable for delivery’ If labour needs to be induced (started), it is useful to know how ripe and favourable her cervix is. Here are the things which will help you to decide if a mother’s cer-vix is ripe (favourable) or not. The more favourable things it has, and the fewer (unfavourable) ones, the closer she is to the start of labour. Section 24.1 tells you how to make these things into a score - Bishop’s inducibility score.
Her cervix is ripe (favourable) if it is: #Dilated so that at least 1 finger goes in. #Shortened so that it is less than 2 cm long. #Soft. #Easy to reach because it is anterior. #Her baby’s head is 3/5 or less above the brim.
Her cervix is unripe (unfavourable) if: #You cannot put your finger into it. #It is more than 2 cm long. #It is firm. #It is posterior (at the back). #His head is more than 3/5 above the brim.
The dilatation of her cervix, and the descent of his head, are the most important ways of monitoring the progress of labour. If we meas-ure and record them, we know if her labour is normal or not. This is what a partograph does - see section 17.13.
■MONITORING CONTRACTIONS is specially important when you are trying to strengthen them by giving her an oxytocin drip (24.2). Check them by feeling her uterus when necessary. Feel it and look at the time on a clock. A more educated mother can monitor her own contrac-tions. She can feel and time the pain herself. Look at the labour record inside the back cover of this book. Near the bottom are columns of five squares, one for each half hour. On the left you will see ‘Contractions per 10 minutes’. Each square is one contraction.
The frequency is the number of contractions she has in 10 min-utes. #If you feel 2 contractions in 10 minutes, fill in 2 squares. #If you feel 3, fill in three squares.
The duration of a contraction is the number of seconds from the time her uterus begins to get hard, until it gets soft again. #If her contractions last less than 20 seconds fill in the square with dots. #If they last 20-40 seconds fill it in with Lines. #If they last more than 40 seconds, fill it in black. Five squares fully filled in black show the strongest contractions.
Caution ! #10 minutes is quite a long time, so sit by her during this time and don’t be disturbed. #Be sure to fill in the contractions in the correct place on her labour record.
‘Efficient contractions’:#Come 3-4 in 10 minutes. #Last 40-60 seconds. #Cause increasing effacement and dilatation in the latent phase. #Cause dilatation of at least 1 cm in 1 hour in the active phase. #Cause the presenting part to descend.
■ EFFACEMENT. Measure the length of her cervix. Before labour starts, her cervix may be up to 4 cm long. During the latent phase of the first stage it shortens. By the time she reach-es the active phase, it is usually completely effaced (0 cm long). Record effacement by writing it in.
Caution! The cervix must be effaced when it has di-lated more than 4 cm. If it seems not to be effaced, it is really only loosely applied - not closely stuck to the baby’s head.
Figure 17-4 THE CERVIX effaces and di-lates during labour differently in primips and multips. A, at 38 weeks there is little effacement in a primip. B, early in the first stage of labour her cervix has effaced but has not yet dilated. C, at 38 weeks a multip’s cervix has started to dilate, but has not yet ef-faced. D, in the first stage of labour a multip’s cervix is dilating and effacing at the same time. E, towards the end of the first stage the cervix of both is completely effaced and dilated. After Llewellyn Jones.
With each picture of the baby there is a view of his head from be-low and a partograph to show the stage of his mother’s labour. ■A, shows his oc-ciput entering the brim of her pelvis on the left side, so she is left occipito-lateral, or ‘LOL’. Later draw-ings show it moving round to the front so that in D, it becomes anterior (OA). She was admitted soon af-ter labour began. His head is 3/5 palpable, it will soon engage in her pelvis and has started to flex. Her membranes are intact, and her cervix is 2 cm long (uneffaced). ■B, his head is now 2/5 palpable, it is more flexed and has just started to turn towards the front (an-teriorly). Her cervix is fully effaced but has not begun to dilate. Her membranes are still intact.
■C, his head is now 1/5 palpable, his neck is more flexed and has turned a little more. Her cervix is now 7 cm so her progress line has been transferred to the alert line on her partograph. Her membranes are still intact. Until now she has been allowed to move and walk about. She has chosen to lie down for delivery. ■D, his head is 0/5 palpable, his occiput is anterior and his scalp is visible. She is almost fully dilated. Figure 17-8
17.2
The four stages of labour
✿✿✿✿There are four stages of labour, and each stage varies in length. The first and second stage each have two phases (parts).
The first stage of labour
begins when a mother’s labour pains start to come regularly and her cervix begins to efface and dilate. The first stage ends when her cervix is fully dilated at 10 cm. The first stage is divided into two phases:①
The slow latent phase
.
During this phase her cervix slowly effaces and then begins to dilate. It starts from 1-2 cm wide, which is what it often is at the end of pregnancy. It ends at 3 cm wide, which is when this phase ends. While the cervix is slowly dilating it is also slowly effacing. When labour starts it is about 4 cm long. When this phase ends at 4 cm dila-tation, her cervix is completely effaced, so that it has no length you can feel. The length of the latent phase is not very useful because: ‚It varies greatly. ªIt is difficult to know when labour starts (18.11). Some experts say the latent phase ends at 3 cm, and some at 4 cm. We take 4 cm - See Section 17.13 - ‘WHO changes its mind’.②
The fast active phase
lasts from the time a moth-er’s cervix is 4 cm dilated, until it is fully dilated at 10 cm. After 4 cm her cervix dilates much faster. When her labour is nor-mal, her cervix should dilate at least 1 cm each hour, while it is dilating from 4 to 10 cm. So the active phase should not last more than 6 hours (10 minus 4 = 6). If it dilates less than 1 cm an hour, the active phase lasts more than 6 hours, and is delayed (prolonged, abnormally slow). Measuring how fast it dilates is a useful way of monitoring (watching) her labour. You can easily do this with the partograph described in Section 17.13. During this active phase she and her baby are at greatest risk. If a primip is going to get a fistula, or a multip is going to rupture her uterus, this is the time when they do it - late in the active phase after 6 cm.The second stage of labour
lasts from the time her cervix is fully dilated (10 cm) until her baby is born. It also has two phases. Usually you only recognise the second one.①
The early phase
. Her cervix is fully dilated, but she has no urge to push.②
The expulsive phase,
when she has the urge to push him out. As she pushes, his head rotates (turns), it crowns (you see it for the first time), it delivers (comes out of her vagina), and then it restitutes (turns back in Line with his shoulders). See also 17.6.The third stage of labour
is the delivery of the pla-centa. The main risks are bleeding - PPH and retention of the placenta. The third stage and its problems are in Chapter Nine-teen.The fourth stage of labour
is the three hours after delivery of the placenta. During these three hours a mother is still in danger of a PPH. After three hours the danger is mostly over - she has been safely delivered! There are other risks after 3 hours, especially delayed PPH (19.11), and puerperal sepsis (25.6).17.3
A mother’s ‘passages’
✿✿✿✿A mother’s pelvis is the bony passage through which her baby goes. At the back of the the pelvis is the sacrum, which is made of five vertebrae joined together. The centre of the upper surface of the first sacral vertebra is the promontory of the sacrum. You can feel this when you do a vaginal examination. On each side are the two innominate
bones, made of the ilium, the ischium and the os pubis (pubic bone) joined together. The two innominate bones meet in front to form the pubic symphysis. The ischial tuberosities are the two bony lumps on the bottom of her ischium; they bear her weight when she sits on them. Behind each ischial tuberosity is an ischial spine, which you can feel when you do a vaginal examination. Each os pubis has a body, a superior ramus (up-per part), and an inferior ramus (lower part). The coccyx is made from four little vertebrae at the bottom of the sacrum.
CPD
- cephalo-pelvic disproportion, his
head
won’t go through her pelvis!
The pelvis has some strong ligaments (fibrous connections): The sacro-tuberous ligaments join the sacrum to the ischial tuberosities. The sacro-spinous ligaments join the sacrum and the ischial spines. The in-guinal ligaments join the front of the pubis to the ilium. By feeling the inguinal ligaments and the symphysis you can feel where the brim of her pelvis is. This is important because you can feel how her baby’s head is descending through it - this is ‘fifths below the brim’ in Section 17.10.
The pelvis has several joints which can sometimes move a little: ●Her right and left sacro-iliac joints between the sacrum and ilium. ●Her pubic symphysis (joint) between her two pubic bones in front. ●Her sacro-coccygeal joint between the sacrum and the coccyx. When she is not pregnant there is very little movement in these joints, but late in pregnancy they loosen a little more. The extra weight of a baby puts much strain on these joints. This explains why some mothers have backache during pregnancy, and afterwards, until their pelvic joints become solid again.
The pelvis has a brim or inlet (an opening at the top), a cavity (‘inside’) and an outlet (an opening at the bottom). The brim is formed by the sacrum at the back, the bones of the pelvis on each side, and the pubic symphysis in front. The outlet is diamond shaped. In front is the pubic arch, at the back are the coccyx, and sacro-tuberous ligaments. The ischial tuberosities are on each side. The upper border of the outlet is at the level of her ischial spines.
The cavity is the curved space between the inlet and the outlet. Its size and shape are important, because it is the ‘passage’ through which her baby goes. Its front wall is short - only the depth of her pubic bone. Its back wall is longer - the whole length of her sacrum and coccyx. Its inlet is slightly wider from side to side (transversely), than it is from back to front (antero-posteriorly). In the middle the pelvic cavity is circular. Its outlet is slightly wider from front to back than it is trans-versely. A baby’s head turns (rotates) as he delivers, so that the longest diameter of his skull can go through the longest diameter of her pelvis. There is a useful way to measure the size of her pelvis. When you do a vaginal examination you can measure her diagonal conjugate - see Section 15.11. This is the distance from underneath her pubic symphysis to her sacral promontory. If it is less than 12 cm she has a small pelvis.
When an Asian or European mother stands, her pelvic brim is at an angle of 60° to the floor, so that the top of her symphysis pubis is level with the tip of her sacrum. Her pelvic outlet is at an angle of 11° with the floor. In most African mothers the brim makes an angle of
nearly 90° with the floor. This can cause delay in the descent of the head during labour, because the baby’s head has difficulty turning the corner into her pelvis.
If labour is to be easy, a mother’s pelvis must be a good size and a good shape. Unfortunately, the human pelvis is only just big enough for the human head. Animals have much smaller heads and much easier deliveries. If a baby’s head is too big, or his mother’s pelvis is too small, or abnormally shaped, there is Cephalo-(head) Pelvic Dis-proportion, or ‘CPD’, between his head and her pelvis - his head is too big for her pelvis. This can cause great difficulty in labour - see Section 22.2.
17.4
Her ‘passenger’
✿✿✿✿If a baby is going to go through his mother’s pelvis easily, he must do it in the right way. His lie, his presentation and his position must be right.
His lie
of a baby describes how the length of his body is lying in her uterus. He can either lie along the length of her uterus (longitudinal lie - normal), or across it (transverse lie). A transverse lie is very dangerous, because he cannot bedelivered, unless: ‚He turns himself, which he can do, provided he does it before labour starts. Or ªyou turn him (do a version), or ‰he is delivered by Caesarean section through her abdomen.
His presentation
of a baby describes the part of him which is lowest in her uterus and is born first. In a cephalic (head) presentation his head is lowest, and is the presenting part. It is the part you can most easily feel when you feel the lower part of her uterus, or when you do a vaginal examination. A cephalic presentation is normal, and all other presentations are abnormal. In a breech presentation his but-tocks are lowest and come first. In a shoulder presentation a shoulder is lowest, and is the presenting part. When a shoulder presents he lies transversely across the uterus, so a shoulder presentation is another name for a transverse lie or an oblique lie.Three cephalic presentations. His neck can flex (bend forwards) or extend (bend backwards or deflex). Flexion and extension make dif-ferent parts of his head come
first in his mother’s birth canal. Depending on how flexed or ex-tended his neck is, the presenting part can be his vertex (the top of his head), or his face, or his brow (forehead). So there are three kinds of cephalic presentation:
●In a vertex presentation his head is well flexed (bent for-ward), so that his chin is on his chest. His vertex then comes first. This is the only normal pres-entation.
Box 17:1 The times of labour
The first stage:
●The latent phase: From 0 to 3 cm. The length of this stage is not useful because knowing when it starts is difficult. ●The active phase: 3 to 10 cm in less than 7 hoursThe second stage:
Less than 60 minutes in primips and 30 minutes in multips.The third stage
. An hour if you gave her oxytocin and three hours if you didn’t. If it lasts longer than 3 hours, she has a retained placenta. (19.4). These are not strict times. A mother’s progress is more important than the time she takes. Is her cervix dilating, how-ever slowly? Is her baby’s head descending? If they are, there is probably no need to worry. These are the longest times, many labours are shorter than this. ●Multips usually dilate faster than primips. ●Mothers with ruptured membranes dilate faster than mothers with intact membranes. ● Slow dilatation with ruptured membranes is more serious than slow dilatation with intact mem-branes.
17.3, 17.4
17.3, 17.4
Figure 17-9
Figure 17-10
Figure 17-11
The second stage starts when a mother’s cervix is fully dilated - 10 cm. ■E, her baby’s head has rotated from LOA, so that his occiput is under her pubis. Try to keep it flexed as it crowns, this will make the smallest diameter of his head come through her perineum. Press on his occiput to allow his head to deliver by con-trolled extension. Deliver it slowly using her con-tractions.
■F, as his face ap-pears use a pad of gauze (not shown) to push her perineum over it. ■G, his head has res-tituted. Gently bend it backwards. His an-terior shoulder is now under her symphysis pubis. Deliver his ante-rior shoulder by gently bending his head and neck towards her anus. ■H, deliver his poste-rior shoulder by pulling him anteriorly.
stage, as in the figure. If it rotates posteriorly, he is born ‘face to pubis’. If his occiput is posterior, labour is slower than when it is anterior or transverse. So LOA and ROA, LOL and ROL, are better positions than LOP or ROP.
In face presentations (21.2) we use his chin (mentum), and in breech presentations (21.1) his sacrum, instead of his occiput. So in a face presentation a baby’s position can be right mento-anterior (RMA, right chin anterior) or LMA, etc.
When you do a vaginal examination, you can feel soft gaps between the bones of his skull. These gaps are called sutures. Where the sutures meet there are larger gaps called fontanelles. At birth the fontanelles are filled with soft cartilage, which slowly becomes bone af-ter birth. There are two fontanelles that you can easily feel: His pos-terior (back) fontanelle is a triangular (three sided) space between his skull bones. His anterior (front) fontanelle has four sides and is diamond shaped. A newborn baby’s fontanelles go up and down as he breathes - like the water in a fountain. This is why they are called ‘fon-tanelles’ - little fountains.
During labour the posterior fontanelle closes temporarily, so that you cannot easily feel the gap between its bones, but you can feel its sutures. Feeling the posterior fontanelle helps you find his occiput. So, if you can find this, and can feel where it is, you can find his position. For example, if you feel his posterior fontanelle in front, on his mother’s left, his position is left occipito-anterior (LOA). If you feel his pos-●In a face presentation (21.2) his head is
ex-tended (bent backwards), as far as it will go. The back of his head touches the back of his shoulders. His face is lowest in her uterus, and comes first in labour. Face presentations are impossible to deliver when his chin (mentum) is posterior (mento-posterior, chin at the back).Delivery is usually easy when his chin is anterior (mento-anterior, chin in front).
●A brow presentation (21.3) is halfway be-tween a fully flexed vertex presentation, and a fully extended face presentation. His brow (forehead) is lowest. Brow presentations are impossible to de-liver vaginally, unless the baby is very small. This is because the distance from his chin to his vertex is the longest diameter of the skull. His head has great difficulty descending through her pelvis.
17.5
His position
✿✿✿✿A baby’s head cannot come out sideways, his head has to turn. His occiput commonly turns for-wards, so that it comes out from under his mother’s pubis. Occasionally, his occiput turns backwards, so that it comes out in front of his mother’s sac-rum (the posterior rotation). He is then born ‘face to pubis’. Most of this turning happens late in the second stage. We need to know where his occiput starts from during this turning. This is his posi-tion in early labour. His occiput can be anywhere round the brim of her pelvis, but it has several common positions:
Left occipito-anterior (LOA). Here his occiput is at the left anterior (front) part of her pel-vis.
Left occipito-posterior (LOP). His occiput is at the left posterior (back) part
of her pelvis.
Left occipito-lateral (LOL). His occiput is at the left side of her pelvis.
The occiput can also be in the same position on the right side. So it can be right occipito-anterior (ROA), right occipito-posterior (ROP) or right occipito-lateral (ROL).
His occiput is never directly anterior or posterior when labour starts, it is always on one side or the other. It rotates under her pu-bis (usually), or opposite her sacrum (occasionally) during the second
Figure 17-12 A BABY’S SKULL. You can feel the sutures on a baby’s skull, and his fontanelle when you do a vaginal examination. His anterior (front) fontanelle lies between his frontal and his parietal bones; it is bigger and softer and has 4 sutures running out of it. His posterior (back) fontanelle lies between his parietal bone and his occipi-tal bone; it is smaller and has 3 sutures running out of it.
17.4, 17.5
17.4, 17.5
Figure 17-13
The commonest and best position is a
well
flexed head
with its occiput anterior.
All other presentations and positions are
malpresentations
.
terior fontanelle at the back on his mother’s right, his position is right occipito-posterior (ROP).
The commonest and best posi-tion is a well flexed head with its occiput anterior. All other presenta-tions and posipresenta-tions are malpresen-tations. If you are having difficulty deciding if a position is ROT or LOT (or ROP or LOP etc.), feel her abdomen and find which side his back is on: his occiput will be on the same side.
17.6
His head descends and turns
✿✿✿✿During labour a baby’s head descends (goes downwards) through his mother’s pelvis. As it does so, it also rotates (turns). At the beginning of labour his head is usually above the brim of her pelvis, and is in a right or left occipito-lateral position. As it descends through her pelvis his head rotates, so that his occiput is anterior, directly under her symphysis. While his head is descending it flexes (bends forwards). You can follow its descent by palpating her abdo-men, and measuring it in ‘fifths above the brim’ - see 17.10. You can also follow how his head flexes and rotates by doing a vaginal examina-tion. Feel his skull and find where his occiput is.
Unfortunately, the dilatation of her cervix and the descent of his head don’t always happen exactly together. For more about this, see Sec-tion 22.1.
17.7
His head moulds
✿✿✿✿During labour a baby’s head changes its shape to fit into his mother’s pelvis. This change in shape is called moulding. There is al-ways some moulding in the second stage. His head can change its shape because the bones of his skull are still separate pieces. They do not join together until he is older. When his skull moulds, its bones come closer together. Then they slide over one another (overlap).
You can feel this overlap at the back of his head, where his oc-cipital bone lies next to his two parietal bones. When moulding is more severe, his parietal bones overlap one another on the top of his skull. You can measure the severity of moulding by making a moulding score - see below.
Pressure on his head makes its lowest part swell with oedema (flu-id). This oedematous swelling is called caput. Caput is a less important sign of pressure than moulding, and is not easy to measure and score. Severe caput is often a sign that CPD is causing obstruction and pre-venting delivery. Severe caput may also mislead you into thinking that his head is lower than it really is.
Severe moulding is an important sign that his mother’s pelvis is not big enough for his head. Moulding is difficult to feel if there is much caput.
■THE MOULDING SCORE. Score for moulding like this: #Bones still separate, score 0. #Bones touching, score +. #Bones overlapping, but when you press with a finger they separate, score ++. #Bones overlapping, but when you press them with a finger they don’t separate,score+++.
17.8
Her membranes rupture
✿✿✿✿A mother’s membranes are the thin layers of tissue on the inside wall of her uterus. Her baby and her liquor (waters) are inside these membranes. Before labour they are intact (unruptured) The liquor be-tween his head and her cervix are her forewaters. The liquor above his head and around his body are her hindwaters. Often, when her mem-branes rupture, only her forewaters come out at first. His head plugs (blocks) her cervix and prevents her hindwaters flowing out until later.
The liquor in her uterus changes towards term. Before 32 weeks there is plenty of liquor around him. You can tell this by trying to move his head from side to side in her uterus. If there is plenty of liquor, his head moves easily. After 35 weeks you feel less liquor, so his head moves less easily. Near term there is very little liquor around him, and after 40 weeks there is even less. After her membranes have rup-tured, you will feel no liquor
- if it has all drained. If you still feel liquor, you are feel-ing her hindwaters which have not yet drained. Occasionally, there is too much liquor (poly-hydramnios, 20.12), so that he is difficult to feel.
If he is healthy, her liq-uor should be clear like water. Meconium (faeces) in it stain it brown or green. This may be a sign of foetal distress (20.1). Scanty (too little) liquor, or liquor which contains meco-nium, is a bad sign. Both indi-cate an increased risk of fetal distress in labour, and an in-creased risk of perinatal death or disease.
In 50% of mothers the membranes remain intact until full dilatation. In most of the other 50% they rupture early in the first stage. Occasionally, they rupture earlier (20.15). This is pre-labour rupture of the membranes or PLROM. When they rupture, the liquor runs out (drains). Sometimes they rupture after 10 cm dila-tation during the second stage. Rarely, they don’t rupture until after birth, so that her baby is born covered in membranes (‘born in a caul’). Both too late and too early (20.15) rupture of the membranes can cause problems. If she remains too long (a day or more) with rup-tured membranes (PLROM) before delivery, bacteria can enter through the rupture and infect the membranes and the baby. This is intrauterine
infec-There is always some moulding in the second stage increas-ing mouldincreas-ing with a high head is a sign of CPD
17.5, 17.6, 17.8
17.5, 17.6, 17.8
Figure 17-14
Figure 17-15
Don’t let her push until she is fully dilated
and
she wants to
tion (IUI, 20.13). Too late rupture of the membranes can cause slow progress in labour.
Should you rupture her membranes? This is artificial rupture of the membranes(ARM) when they have not ruptured themselves.
The advantages of ARM are: ●It can speed up labour a little.●It may sometimes prevent the need to refer her. Perhaps if you refer her, her membranes will rupture spontaneously in the vehicle, and she will deliver beside the road, with all the problems that this has. ●You can see her liquor, and know if there is meconium in it. This suggests foetal distress.
The disadvantages are: ●Prolonged rupture of the membranes (more than 18 hours) increases the chance of infection getting inside the uterus (IUI). (20.13) ●If a mother is HIV positive, rupture of the membranes for more than 4 hours increases the chance she will infect her baby with HIV.
The useful advice is to rupture her membranes when contractions are weak, and she has made no progress after 4 hours.
■
THE MEMBRANES AND THE LIQUOR
■If a mother’s membranes are intact (not ruptured), so that she has passed no liquor, record ‘I’ (intact).■LIQUOR. How much? When you examine a mother during preg-nancy, record how much liquor there is, record it as ‘normal’, ‘reduced’, or ‘excessive’ (too much) for that time in pregnancy.
■WHAT DOES HER LIQUOR LOOK LIKE? It may be clear (like clean water, sometimes with white pieces of vernix in it); this is normal. When a baby is distressed (foetal distress) he passes meconium which stains his liquor brown or green. #If clear liquor is draining, record ‘C’ (clear). #‘B’ is blood. # If there is no liquor score ‘None’. # If her liq-uor is stained green or brown with meconium, record ‘M’ (meconium), and its grade. These are: #Grade 1. Dilute like ‘tea’, you can read print through it if you put it in a glass tube. This is not so serious #Grade 2. Opaque, like soup. You cannot read print through it. Sometimes a sign of foetal distress. #Grade 3 . Meconium only with no liquor. Like thick soup or ‘porridge’ Often a sign of severe foetal distress.
■METHODS of rupturing the membranes - see Section 24.1.
17.9
His head rotates, crowns and
restitutes
✿✿✿✿Several things happen while a baby descends in his mother’s birth canal during the second stage: ●She wants to push. ●His head rotates, so that his occiput lies anteriorly under her pubis. ●His head crowns. ●His head delivers. ●His head rotates back to where it was before (restitutes).!His shoulders rotate. ●His shoulders deliver. ●His body delivers.
She wants to push.
This is a sign that the second stage is probably starting. When her cervix is fully dilated, his head is pushed down into her pelvis. This stretches her vagina and presses on the mus-cles which support it. His head presses on her rectum, and makes her feel that she needs to empty her bowels. It presses on her bladder, so that she feels that she wants to pass urine. This feeling of needing to pass urine or faeces is strongest when her uterus contracts. So she starts to push hard with her abdominal muscles, and her diaphragm, during each contraction. This helps her uterus to push her baby’s head down through her pelvis and out of her vagina.
Her cervix should be fully dilated before she starts to push. So, if you think the second stage has started, check by doing a vaginal examina-tion. If she pushes too early before full dilatation, he may become dis-tressed. This is because the increased pressure in her uterus, caused by pushing, reduces the flow of blood to the placenta. She may also tear her cervix (a small risk). Also, she might become exhausted before the delivery really needs her pushing.
In a breech presentation she must not push until you can see his buttocks without separating her labia. If she pushes too early in a breech presentation, the danger is that his body will deliver, but his head will become trapped by her not fully dilated cervix.
His head rotates (turns),
as it moves down from the brim of her pelvis into its cavity, and out of its outlet. The floor of the pelvis has a different shape from its brim. The muscles of the floor of her pel-vis slope forwards, his occiput hits the floor first and is turned forward. It turns so that its biggest diameter fits the biggest diameter of her pelvis. The biggest diameter of the brim is transverse (side to side). The biggest diameter of the outlet is antero-posterior (front to back). This turning is called the internal rotation of the presenting part. In a vertex presentation, his head enters the brim of her pelvis with his occiput near the side of her pelvis - the occipito-lateral position (right or left). While his head is in the cavity of her pelvis, his occiput moves forwards to lie behind her symphysis pubis. As it does this, the sagittal suture of his skull moves from a transverse (across), to an antero-posterior (front to back) diameter.Sometimes, his occiput starts near the back of her pelvis close to one of her sacro-iliac joints - this is the occipito-posterior position (right or left). When it does this, his occiput usually moves anteriorly (forwards) during internal rotation, so that it lies behind her symphy-sis pubis, as in the figure. But to do this, his head must turn a long way. Her uterus and her abdominal muscles must do more work to turn his head this extra distance.
This is the long internal rotation. So the first and second stages are longer and more difficult when his occiput is posterior - see Section 21.5.
Sometimes, his oc-ciput turns posteriorly to lie over her sacrum. This is the short internal rota-tion, but delivery is more difficult when his occiput is posterior. This posi-tion is called persistent (remaining) occipito-pos-terior (POP). Occasion-ally, his vertex starts its internal rotation from a posterior position, but gets stuck deep in her pelvis, with his occiput transverse, as in Figure 21-27. This is called deep transverse arrest. It can happen: ●because her abdominal muscles and her uterus are weak. Or, ●because the cavity or the outlet of her pelvis are too narrow to let him turn. His vertex will not deliver until it has completed its internal rotation. Because it cannot complete its
in-Figure 17-16
WHAT POSITION
IS HE? First feel for his sagittal
su-ture. Feel for the way it is running.
Then feel at each end to try to find a
fontanelle. If three bones come into
the fontanelle, it is the posterior
fon-tanelle. If four bones come into it, it is
the anterior fontanelle.
ternal rotation in this position, it obstructs (sticks) until she is helped as in Section 21.5.
His head crowns.
When internal rotation is complete, so that his sagittal suture is lying antero-posterior, his head can pass through the outlet of her pelvis. As it does this, it stretches her vulva and peri-neum, so that you can see it. This is called crowning of the head. It may cause tears. These tears are usually posterior, into the muscles of her perineum. If a tear is very big, it may tear into her anus, and damage the muscles (sphincters) which close her anus. Prevent these tears by: ‚con-trolling the delivery of the head, and ªby doing an episiotomy. This is cut-ting the perineum if it is very tight and going to tear. See Section 23.4.His head delivers.
As his head is born it extends on his neck. His forehead comes out first, then his nose, then his mouth, then his chin.His head restitutes .
When his head has delivered, it turns to left or right so that his face is again at right angles to his shoulders. This movement is also called restitution. (back to normal)His shoulders rotate
as they move from the brim of her pelvis down into its cavity and outlet, as in the figure. They rotate because the wide diameter of his shoulders fits best into the transverse diameter of the brim of her pelvis. While they are in the cavity, they rotate into the antero-posterior diameter of the outlet, because this is its largest diameter.His shoulders deliver.
The shoulder under her pubic sym-physis escapes from her vulva first. You can help it to deliver by gently pushing his head back towards her anus. His other shoulder follows. Help this to deliver by lifting his head forwards towards her abdomen. If his shoulders are very big, or are in the wrong diameter of her pelvis, they may get stuck - this is shoulder dystocia, 21.6.His body delivers.
His head is usually the biggest part of him, so if this is delivered, his body usually slips out easily with one or two pushes. If his shoulders deliver safely, the rest of his body never causes problems.17.10
‘Fifths above the brim’
✿✿✿✿If a mother is delivering her baby normally, his head should descend through her pelvis. You can measure this by feeling where his head is in relation to the brim of her pelvis. Is it above the brim? Or is it part of the way through it? The brim is the entry to the pelvic cav-ity, and is level with the top of her symphysis pubis, and her inguinal ligaments. The easiest way to measure the height of his head is to divide it into five parts - ‘fifths’. Examine her abdomen and feel how many of these fifths of his head remain above her brim.
To start with all ‘five fifths’ (5/5) remain above her brim. Finally, ‘no fifths’ (0/5) remain above it, because they have all passed through, and he is safely delivering. When he is 0/5 you can see his scalp between her labia. So fifths go 5/5 ➜ 4/5 ➜3/5 ➜ 2/5 ➜ 1/5 ➜ 0/5.
Always measure fifths above the brim, not the fifths below the brim. You can only do this by examining a mother abdominally. You cannot do it by measuring her vaginally. If there is CPD (head having dif-ficulty going through the pelvis, 22.2) there may be much caput and moulding. His head may elongate (become longer) like a rugby ball (or egg shape) as it moulds. When you examine her vaginally you may think his head is very low, when really there is still some head above the brim:. So always feel how many fifths of his head are above the brim, before you do a vaginal examination. His caput may be presenting at her vulva, but his head can still be 3/5 above the brim. Feeling for fifths of his head passing through her pelvic brim is a much better way of moni-toring its descent, than feeling it pass her ischial spines by examining her vaginally. But vaginal examination is useful: ‚You can monitor the rotation of the presenting part. ªIt is the only way to feel for caput and moulding. ‰It is the only way to monitor the descent of a breech.
Find the height of a baby’s head by palpating his mother’s abdo-men like this. This is for a normal occipito-lateral presentation with a well flexed head. ‘Fifths’ for a face or a brow presentation are the same as ‘fifths’ for a vertex. Breeches don’t have ‘fifths, so you have to measure the descent of a breech vaginally.
■
‘FIFTHS’ ABOVE THE BRIM
■Stand facing a mother’s feet. Put your hands on each side of her uterus, and start palpating from just below the level of her umbilicus. Slowly move your hands downwards, until you can feel her baby’s oc-ciput, and his sinciput. Then decide how much of his head is above her brim. 5/5 The whole of his head is above the brim. You can move it from side to side with your hands and you can feel below it. 4/5 His head is starting to enter her pelvis. 3/5 More than half of his head is Figure 17-17 MEASURING FIFTHS. A, and B, the easy way using
fingers. Feel for the baby’s jawbone in the mid-liine. When he is upside down, it is the ‘top’ of his head. Measure how many fingers this is above her symphysis pubis. This way you don’t need to feel where the occiput and the sinciput are. C, and D, two other ways of showing the descent of the head. E, Experts use the occiput and the sinciput.
Vaginal examination has risks,
especially if your
hands are dirty!
Figure 17-18 A CERVICAL DILATATION BOARD showing the diameter of the cervix from 1 cm to 10 cm. When you do a vaginal examination it is not easy to know how dilated a mother’s cervix is. Cut holes in a board. Imagine you are feeling a mother’s cervix. With your eyes shut, practise feeling the holes until you can always estimate their size correctly. Hang it on the wall of the labour ward, but take it down to feel the holes
still above the brim. After you have felt its broadest part (occiput and sinciput), it narrows again before it disappears. 2/5 Less than half of his head is above the brim. After you have felt its broadest part, it does not narrow again. If you try to move your hands downwards, they move outwards (its widest part is below the brim). 1/5 You can only feel his sinciput. His occiput is below the brim. 0/5 You cannot feel his occiput, or his sinciput, above the brim. His head is now completely inside her pelvis. You may be able to see his scalp if you separate her labia. When you have found the level of his head, plot it with a circle on her partograph.
■’ENGAGEMENT’. When the largest diameter of his head has passed through the narrowest part of her pelvis, this is engagement. We don’t often use this idea in this manual, we use ‘fifths’ instead. His head is engaged when its widest part has gone through his mother’s pelvic brim. This happens between 2/5 and 1/5, depending on how much moulding there is.
■THE EASY WAY OF MEASURING FIFTHS. Measure fifths with your fingers.
A baby’s head is about as broad as your hand. So if his jaw bone (the top of his head when he is upside down) is one hand’s breadth (5 fingers) above the brim of his mother’s pelvis, his head is 5/5. As it descends fewer finger breadths of it will remain above her brim. If it is only one finger’s breadth above, he is 1/5. See Figure 17-16.
■MEASURING FIFTHS WITH BOTH HANDS. If she is very fat, feeling for fifths abdominally can be difficult, and you will find the bimanual (two hands) method useful. Put your left hand on her lower abdomen, and two fingers of your right hand in her vagina. Feel where his head is. Remember what we said above about caput making it feel lower than it really is! How much of his head is above the brim? Feel his head between your hands and try to feel where it is, especially in relation to her ischial spines and pubic symphysis. Is it above or below them? Think of his head in fifths above the brim, and compare it with what you found abdominally. Are they the same?
17.11
Abdominal examination
✿✿✿✿Here is a summary of the steps for doing an abdominal exami-nation during labour. We have described the details of most methods in other sections.
■ABDOMINAL EXAMINATION
■GESTATION BY EXAMINATION. Work out and record a moth-er’s gestation (the duration of her pregnancy) from her dates as in Sec-tion 10.4. This is her baby’s estimated gestaSec-tional age - his EGA. Also work out her gestation by examining her abdomen (15.6). Four things will help you to do this: ①The height of her fundus (15.7). ②Her baby’s size. ③The hardness of his head - it gets harder nearer term. ④How much liquor there is. Do her gestation by dates and by examination dif-fer? If they don’t, see Section 15.8.
■HOW BIG IS HE? Try to estimate his weight. Is he big or small? This needs practice. Practise it by examining many mothers, and weighing their babies after they are born. Your main worry will be very big babies. If her fundus is more than 40 cm, suspect he is very big, and consider referring her immediately, if her progress is slow.
■SCARS (15.6). Is there a scar on her abdomen which might be a Caesarean section? Ask her?
■LIE (15.6). Is he lying longitudinally or transversely ? A transverse lie is very dangerous (21-4) - if she is after 35 weeks, refer her imme-diately.
■PRESENTATION (15.6 ). Is his head or are his buttocks present-ing?
■HEIGHT OF HIS HEAD IN FIFTHS. Do this as in Section 17.10.
■OVERLAP. When a mother is in labour her baby’s head should not overlap (stick out in front) her of her symphysis pubis (overlap of the skull bones is dif-ferent). If it does, his head is having difficulty going through her pelvis. Overlap is a sign of severe CPD. With her bladder empty, place the flat of your hand along the front of her symphysis pubis and the wall of her abdomen: ∎If you cannot feel his head, there is no overlap. ∎If you can feel his head, but it is flush with (in Line with) the front of her symphysis pubis, there is first degree overlap. ∎If it sticks out in front of her symphysis, there is second degree overlap.
17. 12
Vaginal examination
✿✿✿✿You can learn many things by examining a mother vaginally. Measuring the dilatation of her cervix is especially useful, because it measures her progress during the first stage. You can also make sure of the presenting part, and find its position. Vaginal examination is the usually the way you diagnose a face (one in 500 deliveries), or a brow presentation (one delivery in 1000). The other way you diagnose them is by slow progress in labour. These are rare but important emergencies - if you miss a brow or a face, she can easily obstruct.
Disadvantages.
●Vaginal examinations need skill, because it is not easy to know what you are feeling. ●In some cultures moth-ers don’t like it. ●You risk infecting a mother or her baby, especially if:①
You examine her often.②
You use dirty hands or gloves. Cleaning her vagina with 0.25% chlorhexidine reduces the risk of neonatal and puer-peral sepsis. If the start of labour is delayed after a vaginal examination, you can infect her with bacteria on your hands of gloves. ●To protect yourself and her, use gloves.17.10, 17.11, 17.12
17.10, 17.11, 17.12
Figure 17-19
Vaginal examination with
dirty
hands can
kill
a
mother
-
especially
if you do it
often!
Your first vaginal examination during labour is very important. So do it carefully and in detail. Try to avoid infection. Don’t spend too long, and don’t examine her more often than is necessary, because each time you examine her, you risk infecting her. Most labours last 5-6 hours, so you usually only need one or two vaginal examinations. When you have finished your examination record your findings.
■
VAGINAL EXAMINATION
■WHEN? Examine amother vaginally: ‚ When you first examine her in labour. This is very useful in deciding how far labour has already pro-gressed. ª Every 4 hours in the active phase, unless you expect that she will be fully dilated within the next hour. If so examine her in 1 hour. ‰Every half hour in the second stage.
■CONTRAINDICATIONS. #If a mother has been bleeding (APH), never do a vaginal examination, because you may make a pla-centa praevia bleed severely (14.14 ). #If her membranes have ruptured, but she is not in labour (not having contractions), you can infect her with bacteria on your hands or gloves. She can
get intrauterine infection - IUI - see Sections 20.13 and 20.15.
Caution!#If you don’t use gloves you can infect yourself with HIV or the virus of hepatitis B. You can also infect her.#Try to observe eve-rything, and not only one or two things.#Don’t keep putting your hands in and out!
■ EQUIPMENT. A sterile 2 litre receiver or saucepan containing one sterile 15 cm Ko-cher’s forceps, swabbing lotion, 8 sterile cot-ton wool swabs. Plenty of 0.25% chlorhexidine solution. A bottle of antiseptic lubricant (cetrimide cream), and a pair of sterile gloves, which fit you. Disposable plastic gloves are best. If you don’t have them, see below.
■WASH YOUR HANDS with soap and w ater. Scrub your nails with a brush. If possible, wear sterile gloves. Clean her vulva and peri-neum with cotton wool swabs soaked in 0.25% chlorhexidine. Use a spray or use your left hand to wash her vulva. Pour some antiseptic cream over the middle and index fingers of your right hand, and put them into her vagina. ■WHAT DOES HER VAGINA FEEL LIKE?. Notice if her vulva is oedematous (swollen). Her vagina should be moist and warm. If it is hot and dry she is dehydrated. ■HOW DILATED IS HER CERVIX? Measure its diameter (the distance across it)
- without stretching it! Have a board on the wall of your labour ward with circles from 1 cm to 10 cm. Remember the position of your fingers, then go to the board, and see how dilated her cervix is. Use the board to check the diameter of her cervix each time you measure it. Put the first ‘X’ for dilatation on her partograph.
Caution! #You want to know how her cervix is dilating, and it may open a little while her uterus is contracting. So measure it each time when her uterus is not contracting. #When you rest your fingers on a multip’s cervix to measure it, be careful not to stretch it. You may be able to stretch a multip’s cervix to 4 or 5 cm in the latent phase. The
real dilatation of the cervix is what it is without stretching! A cervix which is not fully effaced after 3 cm is rare. So if it is not fully effaced, it is probably less than 4 cm dilated. #Be careful not to overestimate the dilatation of the cervix in a multip.
■HOW LONG IS HER CERVIX? It may be 0, one, two or three cm long. A cervix which is fully effaced has no length, and has been fully ‘taken up’ (100% effaced). See Figure 17-6. It usually effaces be-tween 0 and 3 cm dilatation. If it is completely effaced, record 0 cm. Record the effacement (length) on the same Line as the cervical dilatation. Is it oedematous?
■IS HER CERVIX CLOSELY APPLIED TO HIS HEAD? In a normal labour the cervix fits closely to the baby’s head during a contrac-tion. This is a good sign, because it shows that his head fits easily into her pelvis. A cervix which hangs away from the head is quite common in early labour in grand multips. It is a bad sign. Sometimes, it sug-gests CPD.
■MEMBRANES LIQUOR AND CORD? You can examine these at the same time when you do a vaginal examination.
Are her membranes intact? If they are, you will feel a ‘bag of water’ below his head. If her membranes are ruptured, you will only feel head.
What colour is her liquor? See Section 17.8 Can you feel his cord? When you examine her membranes, don’t forget to feel for his cord. If her cervix has dilated, you may occasionally be able to feel it - this is abnormal (20.14). If you feel it through her membranes it is presenting (pres-entation of the cord, ). If you feel it after they have ruptured, it has prolapsed (prolapse of the cord, ) and is dangerous. See Section 20.14 - Prolapse of the cord.
■ WHAT IS THE PRESENTING PART? This is the part you can most easily feel. It is usually his head (cephalic presentation), but it can be his but-tocks (21.1), his face (21.2), his brow (21.3), or his shoulder (21.4). Rarely, you feel his head and his hand, his arm or his foot. This is a compound (mixed) presentation.
■ WHAT IS THE POSITION OF THE PRE-SENTING PART? Where is his occiput (or his chin or his sacrum)? For example, in a cephalic presentation is he LOA or LOP? Don’t try to feel his position before her cervix is 5 cm - there isn’t enough room. Feel for his fontanelles.
If you are not sure which side his occiput is, remember that it will be on the same side as his back. You can find where this is by palpating her abdo-men. If you find his anterior fontanelle, feel care-fully along each suture until you find his posterior fontanelle. This will tell you the position of his head. If you can only feel his posterior fontanelle, his head is well flexed (a good sign).
Caution!#If you cannot find his posterior fontanelle, but you find his eyebrows and nose instead, he is a brow presentation - a bad sign! #Compound presentations. If you find a hand beside his head, this is a compound presentation, and is harmless. If you find a hand beside a breech, this also is harmless. Manage her as a breech.
■ HOW FLEXED IS HIS HEAD? If it is well flexed, labour will be easier. You can check this by feeling where his fontanelles are. #If you can feel his posterior fontanelle more easily than his anterior fontanelle,
Figure 17-20 VAGINAL TOUCH PIC-TURES. Figures A to E here are very simi-lar to Figures A to E in Figure 21-1 which are viewed from the side, whereas these are felt from underneath.
Has she
bled
vaginally? APH
if so,
don’t
examine her
vaginally!!
Severe moulding -
his head is getting stuck!
Some partographs use 4 cm and others use 3 cm.
WHO
now
advises 4 cm. For the moment, until
we can redraw the figures, we use both.
his head is well flexed. PIf you can only feel his anterior fontanelle, his head is very deflexed, and he may even be a brow.
■ IS THE PRESENTING PART DESCENDING WITH EACH CONTRACTION? If it descends well, expect a normal delivery. This is a useful sign, when his head is high, and you are worried about CPD. If his head descends well with each contraction, labour will probably soon be over. (Editors differ over this sign).
After 7 cm, and especially after 10 cm, the head should be de-scending past his ischial spines with each contraction. Feeling this is difficult at 7 cm and is easier when she is fully dilated.
■MOULDING, CAPUT and LIQUOR. Feel for moulding and caput each time you do a vaginal examination. You can only examine for these when her cervix is more than 4 cm dilated. Record moulding. Look at her liquor. Record its grade (17.7).
■HOW MUCH OF HIS HEAD IS ABOVE THE BRIM? WHERE IS IT IN RELATION TO HER ISCHIAL SPINES? Put two fingers of your right hand in her vagina, and put your left hand on her abdominal wall. Feel his head between your hands, and try to feel where it is, especially in relation to her ischial spines. Is it above or below them? Think of his head in fifths above the brim, and compare it with what you found abdominally. Are they the same?
Caution! If she has CPD, his head can mould and have much caput. Moulding and caput may make you think that his head has de-scended further than it really has. So his head may feel more dede-scended by vaginal examination, than by abdominal examination. If descent by vaginal and abdominal examination is different, abdominal examination is more reliable. So rely on that.
■HOW BIG IS HER PELVIS? Feel this as in Section 15.11. Is it a good size, or does it feel small? If you can reach her sacral promon-tory, her pelvis is very small. She will have difficulty delivering, unless her baby is also very small.
17.13
The partograph
✿✿✿✿The most important part of managing any labour is deciding when a mother is having difficulty. The next decision is what to do about it? Making the right decision will be easier if you have the right information (knowledge) and have recorded it carefully. For this you will need a labour record. The easiest labour record is a piece of A4 paper, printed on one side only, as on the inside of the back cover of this book.
The most important part of a labour record is the partograph. This records how a mother’s cervix is dilating, and how her baby’s head is descending through her pelvis. If her cervix is not dilating normally,
and his head is not descending, her labour is delayed, and perhaps ob-structed. She needs help. A parto-graph is a reliable ‘early warning system’ which helps you to diag-nose the complications of labour before they have done much harm. Is her labour normal, or is it ab-normally slow? If you can diagnose slowness (delay) early, and refer her in good time, you can prevent ob-struction (23.2), fistulae (23.6), and the rupture of her uterus (23.3).
You can also reduce the risk of bleeding (PPH) and ma-ternal sepsis. Obstruction is usually caused by CPD,
and the partograph is an important way of diagnosing it early. You can plot several things on a partograph, and especially: ●the dilatation of her cervix, and ●the descent of his head.
The biggest problem with the partograph is that many health work-ers have problems undwork-erstanding graphs of any kind! Many schools don’t teach ‘graphs’. So first be sure that you really do understand what a Line on a graph means. Another advantage of the partograph is that good handwriting is less important.
You can plot:
①
The dilatation of her cervix
in centimetres. Measure this each time you do a vag-inal examination and plot it with a line of ‘X’s. The line you make by joining the ‘X’s is the progress Line for the dilatation of her cervix. At term, before labour starts, her cervix is usually closed or 1 cm dilated. When it reaches 10 cm, she is ‘fully dilated’, and the second stage starts. During the latent phase of labour, before 3 cm, it dilates slowly.During the active phase it should dilate much faster - 1 cm or more an hour. The squares are 1 hour wide and 1 cm high, so the progress Line for her cervix should go up. It should cross one square (or more) each hour.
②
The descent of his head
in ‘fifths above the brim’. Measure the descent of his head abdominally (17.10) immediately before you do a vaginal examination. Plot it with a circle for his head, using the scale 0/5 to 5/5 on the left of her partograph. The Line you make by joining the circles on the graph is the progress Line for the descent of his head. If his head engaged late in pregnancy, so that sheFigure 17-24
LINES ON THE PARTOGRAPH. The cervix
and the head share the same scale, but the head uses only the
bottom half ‘0’ to ‘5’.
Figure 17-25 WHERE TO RECORD THE TIME OF ADMIS-SION. If you admit a mother in the latent phase, when her cervix is less than 4 cm, record it in square 1. If her cervix is more than 4 cm, find where her ‘X’ goes on the Alert Line, and follow the arrow downwards. This mother was admitted with a cervix of 7 cm, so her time of admis-sion was put in box 12.
17.12, 17.13
17.12, 17.13
Figure 17-22
Figure 17-23
Figure 17-30 MOTHER E. This partograph also shows the progress Line for the descent of the head. On admission at 13:00 she was 1 cm dilated with the head 5/5. At 17:00 she was 6 cm and 4/5. She was now in the active phase so both Lines were transferred. This is what ‘TR’ means. After another 3 hours she was 10 cm and 1/5.
FIGURE 17-28MOTHER C was admitted at 1400 with her cervix at 2 cm. At 1800 it was 6 cm She was therefor in the active stage, so her partograph was transferred to the alert line. 2200 her cervix was 10 cm.
Figure17-26 MOTHER A was admitted at 1600 hours, with her cervix at 4 cm. Because she is already in the active phase (4 cm or more) her cervicograph starts on the Alert Line. By 1700 hours it was fully dilated at 10 cm.
Figure 17-227 MOTHER B was admitted at 0900 hrs with her cervix 1 cm dilated. At 1300hrs it was 2 cm. At 1700hrs it was 3 cm. At 2000hrs it was fully dilated. The latent phase lasted 8 hours and the active phase 3 hours.
Figure 17-29. MOTHER D’s progress Line r E follows the Alert Line almost exactly. See in Figure 17-5. “Recording contractions” When she was admitted 1400 she had one contrac-tion in 10 minutes, lasting less than 20 sec-onds. At 1500 her one contraction in 10 min-utes lasted 20-40 seconds. At 1600 and 1700 she had three attractions like this. At 1800 and 1900 she had four. At 2000 they lasted more than 40 seconds. At 2100 she had five con-tractions like this in 10 minutes
17.13
17.13
Figure 17-31 MOTHER F A common mis-take is to put the next record (‘x’ and ‘o’) in the next square, and not to allow for the time that passes between one observation and the next.
Figure 17-32 MOTHER G is the same as Mother D, but her partograph has Lines drawn in pen, and not printed. The Lines were drawn as soon as her cervix reached 4 cm.
Figure 22-6. DELAY IN THE LATENT PHASE. Mother H’s cervix has stopped dilat-ing and her baby’s head has stopped descend-ing. This is usually because her contractions are weak . See also Chapter 22
Figure 22-10 DELAY IN THE ACTIVE PHASE OF THE FIRST STAGE - after 4 cm and before 10 cm. Mother I’s progress line has reached the Action Line, and her baby’s head has stopped descending.See also Chapter 22
‘lightened’, she will go into labour with his head at 2/5, or less, above the brim (22.1). If she did not lighten, she may go into labour with it at 5/5. By the time it is 0/5 his head is parting her labia. So the progress Line for his head, like his head in her pelvis, should go down. If her labour is nor-mal, his head descends as her cervix dilates. Sometimes, it does not start to descend until her cervix reaches 7 cm.
Monitoring the descent of the head is: ●Helpful in the first stage of labour. ●The most useful way of monitoring the second stage. If a multip has CPD, her cervix may dilate normally, but her baby’s head may not descend. Sometimes, she is 10 cm dilated, while his head is still 5/5 above the brim. When this happens she needs help urgently. This is why you need to plot both the dilatation of her cervix, and the descent of his head.
The two thick black Lines on the partograph are the Alert Line
and the Action Line. The Alert Line tells you when to be specially careful. The Action Line shows the need to intervene (do something). In a health centre ‘doing something’ may mean referring her. Or, it may mean deliv-ering her as in Chapter 22.1. Crossing the Alert Line is only one reason for ‘Action’ (referring a mother), there are many others! If the Alert Line is crossed, the baby is more likely to need resuscitation, and more likely to be stillborn. If the Action Line is crossed, he is even more likely to be stillborn.
What percentage of mothers cross the Alert Line? If you take all the mothers in your district, 90% of them dilate faster than the Alert Line. Only 10% cross the Alert Line. But most health centres see more of the difficult deliveries, and fewer of the normal ones. If you see only difficult deliveries, all your mothers may cross the Alert Line. The percentage of your mothers, whose progress Lines cross the Alert Line, depends on how selected (chosen for difficulty) your mothers are.
What percentage of mothers cross the Action Line? Of the ten mothers in a hundred who cross the Alert Line, seven will deliver nor-mally without crossing the Action Line. Three will cross the Action Line and need help, usually an oxytocin drip or Caesarean section. The number of your mothers who cross the Action Line, will also depend on how ‘selected’ they are. In most health centres many mothers only come, because they are already in difficulty, so they are moderately selected. You will probably find that about 30% of primips, and 10% of multips, will cross the Action Line - if you don’t strengthen their contractions with oxytocin, and rupture their membranes. For whether or not you should do this, see Section 22.4.
What are a mother’s chances of a normal labour if she cross-es the Lincross-es? If the progress Line for her cervix does not cross the Action or the Alert Line, she has about a 95% chance of a normal delivery. It is not a 100% chance, because there are some kinds of abnormal delivery which have a normal progress Line (for example, prolapsed cord, or Caesarean section for foetal distress). If her progress Line crosses the Alert Line the chance of a normal delivery is probably about 70%. If she crosses the Ac-tion Line it is only about 20%. About 20-30% of mothers who cross the Action Line need a Caesarean section.
All mothers need a labour record, but the partograph part of it has different uses in hospitals and health centres:
In a health centre, start all mothers on a labour record. !If a mother has a serious risk factor, transfer her with her labour record. !If she has no serious risk factors, and you think she is going to labour normally, monitor her carefully. If she crosses the Alert Line, think about transferring her. Transport to hospital may take several hours, so she may have reached the Action Line by the time she gets there. If possible, she should get there before she reaches the Action Line. Send her labour record with her.
In hospitals, labour records are also for all mothers. Partographs help to decide when to strengthen labour with an oxytocin drip, or when to deliver the baby, by assisting labour. In hospital, if a mother’s progress Line crosses the Alert Line, watch her more closely. If she crosses the Action Line, something must be done - see Section 22.3 and Pri-mary Surgery Section 18.2.
Several kinds of partograph. #Originally WHO set the active phase starting at 4 cm, then it changed it to 3 cm. Then in April 2000 WHO ad-vised that it go back to 4 cm. Our first edition was drawn with it at 3 cm. In this edition it is back to 4 cm. #Some partographs don’t plot the latent phase, because it is difficult to know when labour begins and therefore how long it lasts. Partographs like this start at 4 cm (or 3 cm). You need to un-derstand the latent phase, even if your partographs don’t plot it. Not plot-ting the latent phase makes partographs easier to use. #Some partographs, like ours here, print the Action and Alert Lines. If your partograph has the Alert and Action Lines printed on it, you will have to transfer a mother’s ‘Xs’ and ‘0s’ to the Alert Line as soon as she reaches the active phase, as with mother E. If your partographs don’t have Alert and Action Lines printed on them, you will have to draw in the Alert Line as soon as a mother reaches 3 cm. Then draw in Action Line 4 hours to the right of it. ■
USING A PARTOGRAPH
■Only start plotting progress Lines for labours which should be normal. Partographs, are useful for breeches. They are not useful for transverse lies, placenta praevia, or brows, etc. These need immediate Caesarean section.
■FILLING IT IN. The partograph is in the middle of the labour record. Along the left side are the figures 5/5ths to 0/5ths for the descent of the baby’s head. Next to these are the figures ‘1 cm’ to ‘10 cm’ for the dilatation of his mother’s cervix. Along the bottom of the graph is the place for the time you do your examination.
Fill in the time to the nearest hour on the square under it. Now write the time in all the other squares, one hour later in each square. If your next examination is not exactly one hour later, put the ‘X’ and the circle between two squares.
Caution! #Remember that a partograph is a tool for managing la-bour - it does not help you to find factors, such as an abnormal lie, which were there before labour started. #A partograph is a decision tool to help you decide things, not an administrative tool (‘just another form to fill in’ !). #There is no point in filling in a partograph after delivery, ‘just to be tidy’! ■HUGH PHILPOTT’S RULES - he invented the partograph! His rules come from South Africa, where services are good. Unfortunately, you may not always be able to follow them. They show that multips labour much f
