1. Dysfunctional Labour
and Partograph
SALSO TEAM
HOSPITAL UMUM SARAWAK

2. Correct diagnosis of labour
• Regular contractions
• Interval gradually shortens
• Intensity of pain gradually increase
• Duration of contraction increase
• Progressive cervical effacement and
dilatation
• “Show’ may be present
• (Progress of labour not stopped by
sedation)
• (Tightening not = contractions)

3. Importance:
• Proper monitoring
• Prevent unnecessary intervention
- Artificial rupture of membranes
- Wrong diagnosis of prolonged
latent phase
- Admission

4. “False” labour
• Uterine contractions impalpable/ infrequent
• Misdiagnosis unnessesary induction/
augmentation  higher risk of failure with
an increased risk of Caesarean section &
chrioamnionitis

5. Definition
• 1st Stage:
– Start of labour  Full dilatation of
cervix
• 2nd Stage:
– Full dilatation  delivery of baby
• 3rd Stage:
– Birth of baby  delivery of placenta

6. Points to observe for…
• Latent phase: Considered prolonged if it is
greater than 8h in nullipara and 6h in
multipara.
• Active phase: On or at the left of an alert
line
• 2nd Stage: Need assessment if expulsive
phase more than 30 minutes. (Max 1 hour
for primips & ½ hour for multips)
– Total 2 hours for nullips & 1 hour for multips
• 3rd Stage : Retained placenta if not
delivered by 30 minutes

7. Labour: Principles of
management
1. Initial assessment
2. Diagnosis and intervention of abnormal
labour
3. Close monitoring of fetal and maternal
condition
4. Adequate pain relief
5. Adequate hydration
6. Emotional support/ supportive companion

8. Initial assessment
• Define risk
– Current & previous pregnancy
– Medical/ surgical problems
– Fetal condition
• Degree of monitoring needed
• Level of staff to manage the patient

9. Partograph
• Diagrammatic representation of the
progress of labour
• “Story of a patient in labour”
• Main components:
• Progress of labour
• Maternal condition
• Fetal condition
• Drugs given

11. Partograph
Patient came in latent phase normal progress

12. Partograph
Patient came in latent phase  normal progress
( Showing station )

13. Partograph
Patient came in active phase of labour  normal/ good
progress

14. Partograph
Patient came in latent phase  normal/good progress

15. Abnormal partograph
(poor progress)
• Latent phase > 8 hours
• Cervical dilatation to the right of
alert line
• Cervical dilatation at or beyond
action line

16. Partograph
Dilatation < 4 cm despite 8
hours of regular
contraction
Patient with prolonged latent phase

17. Partograph
Dilatation < 1cm/
hour in active
phase due to
ineffective
uterine
contractions <
3:10 < 40sec
Patient came in active phase  Primary dysfunctional labour

18. Partograph
Patient came in active phase  Secondary arrest

19. Secondary Arrest
• Arrest of cervical dilatation and
descent of presenting part despite
good uterine contractions.
Absolute CPD Relative CPD
Big fetus /& small pelvis Fetal
malposition

20. Partograph
Intensity and frequency of contractions
(Mild)
(Moderate)
(Severe)

22. Evidence of obstructed labour
• Secondary arrest
• Large caput
• 3rd degree moulding
• Poorly applied cervix to presenting
part
• Odematous cervix
• Maternal/ fetal distress

23. Partograph
• PARTOGRAM X 2 PAGES
= PERINATAL MORTALITY
• PARTOGRAM X 3 PAGES
= MATERNAL MORTALITY

24. Factors affecting labour: 3 P’s
- Power
- Passage
- Passenger
- Position
- Size
- Attitude ( posture of fetus)
ie. flexion/ deflexion/ extension

25. Power
• Adequate effective contractions are
needed for adequate progress of
labour
• Usually 3-4 in 10 min
• Usually 40-60 s duration

26. Augmentation ( oxcytocin)
• Correct dose and titration
• To achieve “efficient “/”adequate”
contraction.
• Observe for hyperstimulation
• Careful consideration in multipara and
patients with previous scar
• Max pitocin licensed for20 mu/min
– Titrate 1, 2, 4,8, 12, 16,20, 24, 28, 32 ml/hr

27. Hyperstimulation
• Prolonged contractions (> 2 mins)
• Frequent contractions (<1:2)
• Tetanic contractions (continuous)
Intervention needed if associated with CTG
changes

28. Passage
• Clinical and X-ray pelvimetry – not
used in modern obstetrics
• Adequacy of pelvis can only be
ascertain through labour and delivery
• Passage may be adequate but might
not be for a big baby

29. Passenger
• Size of baby
• Congenital abnormalities e.g.
hydrocephalus, Anencephaly
• Malposition : Incorrect positioning of
the vertex (OP/ Deflexed head)
• Malpresentation: Presence of
presenting part other than vertex (
face, brow, breech, shoulder,
compound)

30. FHR monitoring
• In latent phase:
* Low risk : Hourly
* High risk : Every 15-30 min
•
• In active phase
* Low risk: Every 30 min
*High risk: Every 15 min

31. FHR monitoring
• During second stage:
* Low risk : Every 15 min
*High risk: Every 5 min or
after each
contraction/pushing

32. FHR monitoring
• Suspicious trace requires
intervention or a referral to a senior
person
• Repeating trace with the hope it will
return to normal is not advisable

33. FHR monitoring
• In a patient in labour (contracting),
fetal heart rate must be documented
especially after a contraction.
• Documentation of “fetal heart heard”
is inadequate
More on CTG in tomorrow’s lecture …

34. Adequate analgesia
• Reduce pain perception & stress
• “Tarik nafas” is not an analgesia at all
• IM Pethidine 1-2mg/kg + Phenergan
0.5mg/kg 6 hourly
• Entonox inhalation (50% O2 and 50%
Nitrous oxide) at the start of contraction
• Continuous epidural analgesia

35. Adequate hydration
• Good hydration is important for
satisfactory labour progress
• Review hydration status regularly
• Urine volume and urine ketones
assessed
• Allow low residual diet / oral fluids in
labour except for high risk cases

36. Companionship / Doula
• Provides reassurance to patient
• Shown to:
– Reduce analgesia requirements
– Reduce Caesarean section &
instrumental
– Improve vaginal delivery rates

37. THANK YOU

39. Moulding Grade 0(No moulding), 1(sutures
opposed),2(overlap;reducible), 3 (overlap; not reducible)

43. Caput succedaneum
• (“Substitute head”)
• Normal occurance due to pressure of
cervix interrupting venous &
lymphatic scalp drainage during
labour.
• Serous effusion between aponeurosis
and periosteum
• Disappear after few hours of birth