Labor and Delivery Procedures

• Principles of Intrapartum monitoring involves the Partograph and Labour Care Guide
• The presentation was prepared by Prof Jamilu Tukur, Federal Teaching Hospital/ Umaru Musa Yaradua University, Katsina

Outline of presentation

• Will cover an introduction to the Partograph including its history, importance, and role in intrapartum monitoring
• Gives practical tips on the utilization of the Partograph, including case studies
• Introduces the Labour Care Guide (LCG)
• Gives practical tips on the utilization of the LCG, including case studies
• Finishes with a conclusion

Introduction to the partograph

• Partograph definition: A graphical representation of events in labor measured against time in hours
• In 1954 Friedman prepared the cervicography
• In 1972 Philpott and Castle, created the first partograph in Rhodesia (now Zimbabwe)
• They used Friedman's cervicograph and adding the relationship of the presenting part to the maternal pelvis
• Philpott and Castle in 1973 introduced the concept of "ALERT" and "ACTION" lines
• In 1987, the World Health Organization produced a partograph to improve labor management and reduce maternal & fetal morbidity and mortality

Importance and role of partograph

• Partographs prevent several complications
• Prolonged labour can be prevented
• CPD (Cephalopelvic Disproportion): Dehydration, sepsis, obstructed labour, fistaulae and ruptured uterus can be prevented
• Inefficient uterine action can be prevented
• Postpartum Hemorrhage can be prevented
• Maternal mortality can be prevented
• Perinatal mortality and sepsis can be prevented

Partograph Usage

• Partograph use is for health workers that can conduct and observe normal labor
• They can perform vaginal examinations and assess cervical dilatation
• They can plot cervical dilatation against time
• Partographs are not for home delivery or untrained health workers

Composite WHO Partograph

• It has 8 hours of latent phase of labor
• The alert line represents minimum progress at 1cm/hr
• The action line is 4 hours parallel to the alert line
• The transfer zone is in between the alert and action lines

Modified WHO Partograph

• The latent phase has been removed
• To be filled from active phase, starting at 4 cm cervical dilatation
• Alert and action line controversies occur at tertiary health facilities

Main Components of the Partograph

• Fetal condition is a main component
• Progress of the labor is a main component
• Maternal condition is a main component
• A small box on the partograph covers a period of 30 mins, while the bigger box covers 1 hour
• Pelvic examination occurs 4 hourly while some centers do 3 hourly
• Period could be shorter when the 2nd stage is anticipated or because of fetomaternal condition
• Partographs are to be filled for all parturients in active phase of labour
• There is room for writing text in the partograph

Patient information

• Patients name, age, parity, and hospital number are recorded
• The date and time of admission is recorded

Fetal condition

• The fetal heart rate is counted and recorded every 30 mins in the 1st stage
• The fetal heart rate ist counted and recorded every 15 minutes in the second stage of labor
• Normal fetal heart rate is 110-160/ minute

Membranes and moulding

• Membranes and liquor are Recorded at every vaginal examination at 4 hourly

• Observations of membrane and liquor involves:

  • I: intact membranes
  • C: clear liquor
  • M: meconium-stained liquor
  • B: blood-stained liquor

• Moulding: Is recorded at every vagina examination 4 hourly

• Observations for moulding:

  • Sutures apart (-)
  • Sutures apposed (+)
  • Sutures overlapped and reducible (++)
  • Sutures overlapped and not reducible (+++)

Cervical dilatation

• Cervical dilation is assessed at every vaginal examination and plot with an 'X.'
• Place the 'X' on the pre-drawn Alert line at the cervical dilation level found
• The vertical line corresponding to this point is the Zero hour
• The Zero hour is where all the first entries will be made in the partograph -Where a partograph don't have pre-drawn alert and action lines, the cervical dilation should be first entered, then draw the Alert line
• Draw the alert line from that point at 1cm/hour to 10cm cervical dilation, afterward draw the action line
• Draw the action line at 4 hours to the right and parallel to the alert line
• Descent of the presenting part marked with O in a cephalic presentation and W in a breech presentation

Uterine contractions

• Chart uterine contractions every 30 minutes; do this by palpating and counting the number of contractions in a 10- minute time period
• Note the duration in seconds
  • Less than 20 seconds (weak): Dots
  • Between 20 and 40 seconds (moderate): Lines
  • More than 40 seconds (strong): shading

Medications and maternal vital signs

• The amount of oxytocin added to the volume IV fluids given if used is recorded
• Any additional drugs given are recorded
• Maternal pulse is recorded every 30 minutes and marked with a dot (.)
• Blood pressure is recorded every four hours and marked with arrow (↑)
• Temperature recorded every two hours
• Urinary volume, protein and acetone are measured and recorded each time the woman passes urine.

Summary of labour

• Is a summary of induction/ onset of labour
• Notes the Method of delivery
• Records observations on the Placenta and membrane
• Records if the Perineum is intact/ laceration/ episiotomy
• Quantifies blood loss
• Notes the Details of the baby
• Observes and notes the Mothers condition one hr postpartum

Case study 1

• Mrs AA. Gravida 2 para 1+0, Hosp no 134, at a gestational age of 39 weeks admitted on January 1, 2025 by 8 am.
• She has 3 contractions in 10 mins lasting 40s
• Fetal heart rate was 140/ min, with a descent of 3/5
• Pelvic exam shows Cervix 7 cm dilated
• Membranes absent, with No caput or moulding Clear liquor. Pr 80/min, BP: 120/80mmHg and Temp 36.8c
• At 11am her contractions are 4 in 10 mins lasting 50s, descent 2 /5 and FHR 156/min
• She is Fully dilated with Clear liquor, PR 90/min, BP 130/90mmHg and has a Temp of 37.2c

Case study 2

• Mrs BB. Gravida 3 para 2+0, Hosp no 2355, at a gestational age of 38W5D weeks admitted on January 1, 2025 by 8am
• She has 3 contractions in 10 mins lasting 40s, Descent 3/5 and her Fetal heart rate was 150/ min
• A pelvic Exam shows Cervix 5 cm dilated, Membranes absent, with No caput or moulding Clear liquor, Pr 80/min and BP: 130/80mmHg, Temp 37.4c
• At 12 noon she has contractions 2 in 10 mins lasting 20s
• Descent 2 /5, Cx 6 cm dilated, Clear liquor, PR 90/min, BP 130/90mmHg, FHR 160/minute and a Temp: 37.2c

Labour Care Guide

• It is a monitoring tool developed by the WHO
• It aims to provides good quality, evidence based and respectful care during the intrapartum period
• Adopted for use in Nigeria by the FMOH

Aim of the LCG

• To guide the monitoring and documentation of the well-being of women and babies and the progress of labour

• To guide skilled health personnel to offer supportive care throughout labour to ensure a positive childbirth experience for women

• Assist skilled health personnel to promptly identify and address emerging labour complications

• Reference thresholds for labour observations trigger reflection and specific action(s) if an abnormal observation is identified

• Prevent unnecessary use of interventions in labour

• Support audit and quality improvement of labour management

• The LCG has been designed for the care of women and their babies during labour and childbirth

• Assessments and observations are essential for the care of all pregnant women, regardless of their risk status

• Documentation on the LCG of the well-being of the woman and her baby as well as progression of labour should be initiated during active phase of the first stage of labour when cervical dilatation is 5 cm or more

• Active stage documentation is regardless of a patient's parity and membranes status

• LCG is for all women in labor with additional monitoring and care for high-risk women

• It is used when women have entered the active phase of the first stage of labour at 5 cm or more

• It is designed for use at all levels of care in health facilities

Sections of the LCG

• Identifying information and labor characteristics at admission

• Supportive care

• Care of the baby

• Care of the woman

• Labour Progress

• Medication

• Shared decision-making

• All observations entered into the NLCG, have a time and reference axis

• Time axis is the horizontal time axis for documentation

• The reference axis represents the vertical reference values axis for determination

• Assess any deviation for normal observations

• The decision to intervene in the course of labour is based on deviation from expected assessments

• LCG provides explicit reference values for labour observations

• A section documents shared decisions to address any deviation from the expected norm

ARCP approach

• Assess → Record →Check → Plan approach

• Involves assessing the well-being of woman and her baby, and progress of labour

• Document labour observations

• Check reference threshold and compare labour observations with reference values in the “Alert" column

• Decide if and what interventions are required in consultation with the woman, and document accordingly

• "Alert" column presents thresholds for abnormal labour observations that require further assessment and action by the healthcare provider

• If labour observations do not meet any of the criteria in the "Alert" column, labour progression and care should be regarded as normal There would be no medical intervention warranted

###Observations/entries

• The frequency of observations mirrors the partograph design.
• Nomenclature to complete the LCG: numerical or with an abbreviation for "Alert" column.

How to complete LCG

• Demographic and labor characteristics, such as the woman's age, gestational age, serology results, hemoglobin, blood type and Rh factor, referral status and cause, symphysis-fundal height

• Labour companionship, access to pharmacological and non-pharmacological pain relief

• Ensure women are offered oral fluid

• Techniques to improve women's comfort

• Labour support is recorded hourly

• Fetal heart rate, amniotic fluids, fetal position,moulding head of baby and caput

• Maternal vitals are assessed through pulse blood pressure, temperature and urine

• Regular observation of the frequency and duration of contractions

• Assess cervical dilation and descent of the baby's head

• Facilitates consistent recording of all types of medication and their dosages

• Consistent recording of all assessments

• This section aims to facilitate continuous communication with the woman and her companion

• Consistent recording of all assessments and plans agreed upon

• Observations are made and recorded during the second stage

Conclusion

• LCG is evidence based and adaptable in all clinical care settings
• However, LCG needs training for effective implementation

This quiz covers essential procedures during labor and delivery, focusing on proper documentation, interventions, and fetal monitoring. It addresses key aspects such as managing labor stages, understanding modes of delivery, and prioritizing newborn care. The questions emphasize adherence to protocols and patient comfort.