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CURRENT MANAGEMENT OF LABOUR

FIRST STAGE
Defined as stage of cervical os dilatation from zero to 10cms in
which there are painful palpable uterine contractions and exist in
two phases viz latent and active phase.
Latent phase concept: The latent phase marks the cervical os
dilatation from zero till 3cms in primgravida or 4cm in multigravid
associated often with painful, palpable contractions of increasing
frequency and intensity of at least one in 10 minutes interval. It is a
prodromal stage which show much variation in duration and
represents the earliest part of first stage labour which essentially is
innocuous and not predictive if any sinister subsequent Active phase
problems.
Diagnosis: Parturient at term with contractions at least one in every
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10 minutes interval and cervical os dilatation less than 3cm in
primigravida or 4cm in multigravida.
Approach to management: In the absence of any other
complications (like post-datism, hypertensive diseases fetal
distress or rupture of membranes) treatment is observation until
conversion to active phase labour.
Classifications:
(e) Normal latent phase when the duration of the latent phase is
within 8 hours before conversion to Active phase
(f) Prolonged latent phase when the latent phase duration is over 8
hours but within 24 hours.
(g) False labour is a latent phase case where the latent phase
features persist over 24 hours without conversion to active
phase. Thus false labour is the diagnosis in retrospect of a
parturient in
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whom the latent phase feature is still persisting after 24 hours without
conversion to active phase. False labour may be contractile or non
contractile. Latent phase is a mere pro dromal stage which deserve
treatment with observation only and no intervention in the absence of
any complications.
Active phase concept: This is the later aspect of first stage labour
marking the cervical os dilatation from 3cms in the primigravida or
4cm in the multigravida until full cervical os dilatation at 10cm and
often is the inferred aspect of labour in which strong enough
contraction is generated and sustained to lead on to the delivery of
the fetus and placenta per vagina.
It is characterised by regular, painful palpable contractions of
increasing frequency and intensity associated with progressive
effacement and dilatation of the cervical os, and descent of the
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Presenting part leading to the delivery of the fetus and placenta per
vaginam with minimal risk to mother and baby within a 12 hours
duration.
Diagnosis: A parturient with contractions at least one in every 10
minutes interval with cervical os dilation of at least 3cm in the
primigravida and 100% effacement of the cervix or 4cms in the
multigravida with at least 50% effacement.
Duration: Active phase is 12 hours in all women irrespect of Age,
Parity or race. Any duration over 12 hours is prolonged labour.
Monitoring of Active phase: This is objectively done with the
cervical dilatation rate derived from at least two sterile consecutive
vaginal examination in the parturient. The normal rate of progress
is nowadays one centimeter per hour. Any cervical os dilatation rate
of less than one centrimeter per hour is slow labour progress.
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Operational Management of Active phase
This is founded on the followings –
- Management begins when the first VE in labour confirms
parturient in active phase.
- Assessment of progress in active phase in best with cervical
dilatation rate and not descent or contractions.
- The normal progress in active phase is cervical dilatation rate
of 1cm per hour provided fetal membranes are ruptured.
- Supervision is based on the anticipation that progress will be
as for normal rate of 1cm per hour hence VE at some
specific interval like (2-4) hourly
- Slow Active phase labour is a cervical dilatation rate less
than 1cm per hour.

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CONTD
-Active phase labour is the phase where intervention is
useful when progress is abnormal like slow labour.

Problems of Active Phase


- Failure of cervical os dilatation rate at 1cm per hour is the
commonest problem and when not corrected will result in
prolonged labour and its sequelae
- The commonest cause of failure to dilate at the rate of
1cm per hour is uterine inertia especially in primigravida
uterine inertia also occurs in 2nd stage to cause poor head
descent and poor maternal efforts and lack of the Urge to
push in the absence of C.P.D. In the 3rd stage uterine
inertia may manifest as uterine atony and 1o P.P.H

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-Uterine inertia in any stage of labour responds well to oxytocin
infusion treatment with improved cervical dilatation rate in 1st
stage, improved contractions and head descent in second stage and
improved contractions to prevent primary P.P.H in the 3rd stage
Complications of Active Phase
-Prolonged Labour: This is active phase duration of over 12 hour in
all women. It is often proceeded by slow labour progress which is
cervical os dilatation rate of less than 1cm per hour
- Labour dystocia : This is active phase cervical os dilatation rate of
less than 1cm per hour sustained for up to 2 hours and beyond. The
significant is that it marks the point at which if corrective measures
where instituted the cervical os dilatation rate may be restore back
to normal.

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-Cephalo-pelvic disproportion (C.P.D.): This is a misfit between
the fetal head and maternal pelvis in active phase labour
manifesting as slow labour progress on the presence of good and
strong contraction as evidence by feto-maternal head squeeze as
mild moderate ca put and moulding in the absence of feto
-maternal distress. The treatment is Em c.s except when it is due
to occipitoposterior position diagnosed as deep – transverse arrest
which may be managed with rotation and if this is successful
hence vaginal delivery.
-Obstructed Labour: this is when a misfit in active is associated
with failure of labour progress in the presence of good
contraction manifesting as substantial feto-material squeeze with
moderate – severe caput and moulding often with feto – maternal
distress.
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-Cervical dystocia: This is when there is complete failure of the
cervix os to dilate in active phase in the presence of good
contractions from a primary fibrotic disease of the cervix. The
treatment is Em C.S in order to prevent a cervical tear which may
involve the lower segment.
Cervical Stasis: This refers to active phase cervical os dilatation
which is static after an initial dilatation between two or more
consecutive VE in a cervix without any prior fibrotic lesion. It
may be a part of the clinical finding in C.P.D. obstructed labour or
even uterine inertia.
Prevention of Active phase complications:
-The most feared complication of active phase is prolonged labour.
-Virtually all the complication of active phase is preceded by a
prior failure to dilate at the cervical dilatation rate of 1cm per hour.
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-Hence the best way to prevent all the complications of Active phase
is to strategy that easily identify women manifesting with slow
labour progress or less than 1cm per hour cervical dilatation rate for
prompt treatment
-Active management of labour is the strategy that is aimed a t the
prevention of prolonged labour and emphasizes regular assessment to
monitor cervical dilatation rate for diagnosis of slow progress.
Active Management of Labour (AML)
Past, Present and Future
The Concept
1. Active management of labour (AML) is a structured protocol
for the management of all parturients in labour first enumerated by

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O’Driscol and Associates from Dublin Ireland in 1969
with the aim of reducing prolonged labour which was the
most challenging obstetric problem at the time.
3. The protocol was based on the anticipation of progress in
labour at a cervical dilatation rate of 1cm per hour in all
parturient with early identification and prompt treatment of
slower than 1cm per hour cervical dilatation rate till delivery
4. The protocol was used for 1000 consecutive primigravidae
the outcome of which was published and showed excellent
results with very low prolonged labour rate, low caesarean
section rate; babies with good apgar scores and mothers that
were happy and contented.
5. The protocol that brought this monumental achievement of
extremely low prolonged labour rate and C.S rate was
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rapidly spread world wide as the Active management of labour.
In content AML involved senior obstetric staff in the monitoring of
labour from onset anticipating standard normal progress of 1cm
per hour cervical dilatation rate as against the passive attitude of
the past in which senior staff were involved only when problems
had occured.
Principles of Active Management Labour
These are a set of belief system based on the knowledge of labour
dynamics upon which the protocol for AML was based.
6. All women in labour require confirmation of active labour as the
basis to commence this active involvement of senior obstetric staff
in the AML
7. ARM in early labour facilitate rather than complicates labour
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CONT
2. Cervical dilatation rate is the most objective basis for assessing
progress in labour and not the subjective assessment of
contraction quality or head descent.
3. The normal labour progress is a cervical dilatation rate of 1cm
per hour from active labour until delivery.
4. Efficient labour supervision is based on the anticipation of
progress at the rate of 1cm per hour and through repeated VE
at short interval pick up slower than 1cm per hour cervical
dilatation rate early for prompt treatment to improve progress.
5. Prolonged labour is more commonly due to uterine inertia and
not C.P.D especially in the primigravida and prolonged labour
often has an antecedent slow labour progress or less than 1cm
per hour cervical dilatation rate.

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2. The commonest cause of failure to dilate at the rate of 1cm per
hour is uterine inertia which may manifest as hypo; hyper, or
incoordinate uterine action especially in the primigravida.
Uterine inertia may also manifest in the second stage as poor
head descent or poor maternal expulsive efforts
3. Uterine inertia responds well to oxytocin argumentation with
improves cervical dilatation rate especially when the
augmentation is begun early without any delay or lag in time.
4. In the primigravida before there is a diagnosis of C.P.D.
oxytocin augmentation must first be instituted to eliminate
uterine inertia first even when the contractions are deemed
clinically adequate
5. The primigravida uterus is immuned to uterine rupture with
oxytocin augmentation except with a previous scar or
manipulations in labour. Prof AAE Orhue
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CONT
2. When a parturient is exposed to active labour contractions for
over 12 hours spiraling feto maternal distress will usually set
in.
3. Companion ship to a parturient in labour assist to reduce the
need for analgesia and increase the capacity to cope with the
distress of the labour process.
The protocol for Active management of labour by O’Driscoll from
Dublin Ireland
5. All parturient were examined in L/ward by senior obstetric
staff to confirm that active labour was established.
6. When active labour was confirmed A.R.M. was performed (if
membranes intact) and the VE was repeated every hourly for
the first 3 hours to assess the cervical dilatation rate
exclusively.
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2. When at the hourly V.E., cervical dilatation rate was 1cm per
hour for the first 3 hours, V.E. was then repeated every 2
hourly until delivery.
3. When cervical dilatation rate is less than 1cm per hour at any
of the VE, oxytocin augmentation was instantly instituted to
treat this problem and VE was performed still every hourly
while on the augmentation regimen.
4. Oxytocin augmentation was also instituted for women in the
second stage with poor head descent and poor expulsive
maternal efforts without C.P.D to correct uterine inertia in the
second stage.
5. The oxytocin regimen was 10 units unto a litre titrated to
improve the contractions so as to make cervical dilatation rate
at least 1cm per hour. The oxytocin infusion was only a
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duration of 4 hours or one litre of fluid infused. If there was no
improved progress then em C/s was performed for C.P.D.
3. All women in labour were assigned one nurse who stayed with
her till delivery as companion and help monitor vital signs and
fluid administration where necessary.
4. All women in active labour were given the firm assurance that
labour would not last a duration beyond 12 hour at the
beginning of the labour and repeated at subsequent assessment.
5. The labour pain relief was regularly with narcotic analgesics
but epidural was allowed for those who requested.
6. All the findings at the V.E. and other vital signs were recorded
on a partograph which had a diagonal line running from zero
at zero time on the x-axis to represent zero cervical os
dilatation to 10 cm on the y-axis at 10 hours later to represent
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CONTD
full cervical os dilatation. This was an ALERT – Action line
complex and women whose cervical dilatation graph cross
this line were progressing less than 1cm per hour and shows
augmented with oxytocin infusion.
Outcome of the Dublin Active management labour protocol
The results of the use of this protocol in the labour management of
1000 consecutive primigravida was published in 1969 with the
following outcome.
5. Prolonged labour rate was about 1%
6. The caesarean section rate was under 5%
7. The Babies mostly had good apgar scores
8. Mothers had good morale and full contentment.

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CONTD
2. There was low prevalence of the need for analgesia in labour
due to the excitement of anticipating delivery within 12 hours.
COMMENTS:
- These results implied that AML as embodied in this protocol
was the ante date to the then dreaded problem of prolonged
labour and its sequelae often always heralded by a prior slow
labour progress.
- The bonus effect of AML which were the low C/S rate and
babies with good apgar score were very attractive and led to the
great zeal for the use of A.M.L. in most parts of the world
especially in Europe and U.S.A.
Problems of A.M.L. from the Dublin protocol
With all the advantages of AML there were some problems which
formed the basis of the criticism of AML as practiced in
Dublin.
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CONTD
2. The need for Senior obstetric staff to confirm the active labour
before starting the A.M.L. protocol.
3. The hourly VE was feared would introduce infection in labour.
4. The high augmentation based on not dilating at the cervical
dilatation rate of 1cm per hour even from early labour.
5. The oxytocin augmentation regimen which was only for 4 hour
duration or one litre of fluid only.
6. The need for a nurse for every parturient through out labour.
7. The overall cost consequent on high consumables from the
frequent V.E. and staff required.

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CONTD
Criticism of AML
The problems as enumerated made it difficult for the AML as
practiced in Dublin to be fully implemented in several units
and led to the inability to fully reproduce the same excellent
results especially with respect to the low C/S rate. However
AML was accepted as reducing the prolonged labour rate but
the high oxytocin augmentation rate was a major issue. This
led to modification of the protocol to suit particular localities.
Modification of protocol for A.M.L.
• Philpot and Castle (1972): Philpot produced a protocol for
labour management based on a composite partograph he
designed in which progress was assessed at the cervical
dilatation rate of 1cm per hour as the normal standard but

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CONTD
Parturient who progressed less than 1cm per hour did not have any
intervention until after 4 hours delay from this normal progress.
This 4 hours delay was imposed by the circumstances of poor
manpower distribution to effect the appropriate intervention
rather than a deliberate design to try this 4 hours delay.
- On the partograph the cervical dilatation of 1cm per hour was
visually represented on that partograph by the Alert line
representing a cervical dilatation rate of 1cm per line from an
admission cervical os dilatation rate of 1cm until full 10cm
dilatation 9 hours later.
- The intervention at the 4hours delay from the normal 1 cm per
hour cervical dilatation rate was visually represented on the
partograph with the Action line drawn 4 hours to the right and
parallel to the Alert line.
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The details of the Philpot’s protocol is as follow:
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CONTD
2. Parturient in labour were managed by the midwives and medical
officers without obstetric knowledge at the peripheral centres
several of which were around the main tertiary centre in Harare
then called Saliusbury in the Rhodesia but now called
Zimbabwe.
3. When the parturient achieved a cervical os dilatation of 1cm, all
findings in the labour (vital signs of the mother and fetus and
cervical os dilatation) were now recorded on the specially
designed composite partograph on which had been constructed
the Alert and Action line as already described.
4. Repeat VE was performed at 4 hourly interval (unlike the
Dublin protocol which was performed at hourly intervals) and
plotted on the partograph. The contractions were assessed
every half hourly. FH every 15 minutes but BP; respiration and
pulse every hourly. Urine assessment for volume and content
was every 2 hourly but body temperature was every
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CONTD
4 hourly interval till delivery.
3. When the cervical os dilatation graph crossed or touched the
Alert line, the parturient was then transferred from the
peripheral unit to the tertiary centre because in crossing the
Alert line the cervical dilatation rate was now less than the
expected normal rate of 1 cm per hour (visually represented by
the Alert line) which problem required obstetric knowledge
and skill to assess the cause and effectively treat.
4. The actions often instituted at the Alert line were I.V. infusion
for rehydration and to keep the vein open for the transfer
process. The distance between any of the peripheral centres
and the tertiary unit was not more than a duration of 4 hours by
the most accessible means viz treking driving etc.

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CONTD
2. At the time of arrival at the tertiary unit 4 hours later some
may have delivered or nearly delivered. For the undelivered
parturient VE was performed at 2 hourly intervals and plotted
on the partograph in which the Action line (drawn 4 hours to
the right and parallel to the Alert line) would have been
crossed.
3. For those who cross the Action line it means the labour
progress has been less than the normal 1cm per hour for 4
hours or over by factors requiring instant treatment at the
tertiary unit. The women in this category at the tertiary
centre who were being managed by the midwives and Junior
staff were now moved into the intensive care areas for Active
treatment.
4. The action taken was now to begin A.M.L. with firstly A.R.M
and when progress did not improve after 2 hours then
oxytocin augmentation was done for a maximum duration of
6 hours.

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CONTD
Repeat VE was at 2 hourly interval.
3. Women who progressed well with the augmentation were
delivered vaginally but those who did not progress had the
labour terminated with C/S
Outcome of Philipots protocol
The result of the use of this protocol to treat 624 primigravida
showed excellent outcome with a prolonged labour rate of 10%
a perinatal mortality rate of 5.8% and an oxytocin
augmentation rate of 22% and C/S rate of 9.9%.
- This protocol entailed VE to assess progress at (2-4) hourly
intervals, instituted oxytocin augmentation after 4 hours delay
and did not assign one nurse per parturient in labour.

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CONTD
-The excellent result was achieved at low cost for staff and material
and therefore a good format for A.M.L. for those in resources poor
zones of the world like the developing countries. This is why this
Philpot protocol for A.M.L. spread rapidly through out Africa and
other developing countries.
- It was not clear from this work of Philpot that good results can be
obtained for reducing prolonged labour and C/S without strictly
adhering to the protocol of A.M.L. from Durbin Ireland.
Criticism of Philpot's protocol
-Inspite of the good result of the A.M.I. By Philpot several workers
criticized it on several issues.
(1) The Alert line from 1cm cervical os at admission time to
10cm at 9 hours later was deemed as capable of concealing gross
delay in labour progress in those with advanced cervical os
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CONTD
dilatation like (6-9)cm as normal with serious consequences.
3. The 4 hour separation between the Alert and Action line as
been too long a delay for which the cause of the poor progress
may not be easily reversible or corrected to allow normal
progress.
4. The basis of the Alert line of 1cm per hour as representing the
slowest 10% African Primigravida in labour was deemed
peculiar only to African and therefore may not be applicable to
other races in Europe and U.S.A.
Other Protocol of Active Management of Labour
Because of these criticism other A.M.L. protocol were evolved as
follows:
1. Studd’s Labour Stencil, in 1976 Studd produced the equivalent
of Alert line based on the cervical dilatation on admission into
the labour ward.
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CONTD
When the cervical os dilatation progress cross the line drawn for
the stencil based on the admission dilatation a further two hour
was allowed before oxytocin augmentation.
- The outcome was a a reduced prolonged labour rate and c/s
rate but augmentation was about 32% as against the 55% by
the O’Driscoll and 22% by Philpot.
4 Arugumarran . In 1987, Arugumarran introduced further
modification to the Active management of labour protocol.
This was (a) the individual Alert line by which the admission
cervical os dilatation of the parturient was used to construct the
Alert line for her on a slope of 1cm per hour until delivery and
a consequential action line.
(b) The advocated separation between the Alert and Action
line was 2 hours and not four at the centres where there would
be no transfer of the women for further treatment as in tertiary
unit.
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CONTD
© The oxytocin augmentation was for a duration of 8 hours
instead of 4 hours at advocated by O'Driscoll or 6 hours as
advocated by Philpot.
By these modification much improved results were obtained for
reduced prolonged labour rate and c/s low perinatal mortality rate .
Critical issues in A.M.L.
-Because of cost and other constraints it has been difficult to fully
reproduced O'Driscoll work in Dublin even with randomised
controlled studies.
-- Most studies critical of the A.M.L. protocol from Dublin
implemented only aspects of the protocols or began the A.M.L.
when as yet the woman had not established Active labour.
-The issue is that capacity to fully correct the slower than 1cm per
hour cervical dilatation rate depend on picking this anomaly at the
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CONTD
Point of its occurrence for timely correction which is possible only
with hourly, VE in labour to monitor cervical os dilatation.
-This way, slow labour will be picked up as a it occurs and
immediate treatment with oxytocin will correct this to substantially
reduce the prolonged labour rate and also the bonus effect of lower
c/s rate and perinatal mortality rate.
-- The A.M.L. by Philpot dictated by the circumstance of the poor
resources has demonstrated that not applying the strict A.M.L.
protocol from Dublin can produce equally good result with respect
to low prolonged labour and c/s rate with excellent feto maternal
outcome.
- The most essential element in A.M.L. is to supervise labour based
on closed monitoring with VE at specific intervals to assess the
cervical dilatation rate aiming to identify slower than 1cm per hour
cervical
10/22/08dilatation rate treatment.
Prof AAE Orhue 31
CONTD
- When cost and other constraints are prevalent the Dublin
protocol can be modified to suite the realities with VE at less
frequent intervals and oxytocin augmentation delayed beyond
the immediate. The outcome is always some improvement
but never equal what the Dublin experience achieved. This is
the way to ensure that A.M.L. is practicable in all areas world
wide with great benefit.
Present Practice of A.M.L.
The practice of A.M.L. presently is divided into:
5. Those who belief and practice A.M.L. as the Dublin protocol
without modification. Such is the case in most parts of the
republic of Ireland and several units in U.K.
6. Those who practice A.M.L. using some modification of the
A.M.L. protocol from Dublin. In this group, all practice is
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CONTD
based on the anticipation of labour progress at the cervical
dilatation rate of 1cm per hour as the normal standard
through regular VE to assess cervical dilatation rate of the
parturient aiming to prevent prolonged labour.
The modification is with respect to the followings:
d) The interval for the VE at (2-4) hourly instead of the one
hourly interval.
e) The interval or duration of delay in the cervical dilatation
rate of less than 1cm per hour before intervention like
oxytocin augmentation is begun.
The Dublin protocol advocates instant oxytocin augmentation at
the point of occurrence from the hourly VE (This is
prophylactic augmentation) but modification specify delays
of (2-4) hours from progress less than 1cm per hour.(This is
therapeutic argumentation because this is now treating
labour dystocia)
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CONTD
Often the duration of delay before the intervention is reflected in
the separation between the Alert and Action lines on the
partograph in use.
c. The duration of the augmentation for (6-8) hours instead of
the 4 hours in the Dublin protocol.
d. The Alert and Action line on the partograph to be drawn for
each parturient based on the cervical os dilatation at the
admission into labour ward in Active phase called the
individualized Alert and Action line or permanently drawn
Alert and action lines on the partograph.
e. Whether the partograph should contain all the full composite
features to provide for the documentation of the entire
details in the laboring woman or contain only a few selected
parameter like cervicogram only and strict FH Range of
100-160 without space for Head descent, and maternal vital
signs as the Dublin partograph.
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CONTD
The W.H.O. Protocol
The W.H.O. Supported the modified protocol by adopting and
recommending a composite partograph adopted from Philpot
version with the following modifications.
iv. Included space for recording findings in the latent phase.
v. Printed Alert line from 3cm at admission to 7cms 7 hours later
at a scope of 1cm per hour as the normal standard. The Action
line was printed as for Philpot 4 hours to the right and parallel
to the Alert line.
vi. The partograph retained all the composite features.
Problems of the W.H.O. Protocol
1. By recording latent phase on the partograph there may likely be
some premature intervention in latent phase which is a phase of
labour that deserved only observation till conversion.
Furthermore W.H.O. classification
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CONTD
of latent phase into normal and prolonged latent phase tended
to suggest that prolonged latent phase was an extreme
anomaly.
3. No specific actions recommended of either the Alert and
Action line to the extent that today action like ARM; IV
infusion commencement and oxytocin augmentation are
commenced of variable period e.g. at Alert line or action line
and in some situation between the Alert and action line.
4. In maintaining 4 hours from the the Alert and Action line , the
W.H.O.protocol encouraged the delay of 4 hours before
intervention which is unacceptable at a tertiary unit.
5. In recommending the protocol and partograph for use in all
settings of Health Care W.H.O. did not clearly specify the use
to which the Alert line in particular should be put at the
tertiary unit where parturient do not need transfer for
improved care as a result of slow progress.
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CONTD
(b) The Alert line now begin from 4cm instead of 3cm implying
that active phase diagnosis for all parities now shall be with
cervical os dilatation of 4cm without reference to effacement
which technically is more difficult for the junior staff to elicited.
(c) The entire partograph provide space for recording only for a
duration of 12 hours which is the normal duration of active
phase.
However even in the new W.H.O. Partograph there is still 4
hour between the Alert and Action line who will still be a
problem at the secondary and tertiary units and a universally
recommended action at the Action line in all settings of Health
Care has still not be made.
Active Management of Labour in current Practice
For all practical purposes A.M.L. is a structured protocol for the
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CONTD
2. In locating the Alert line from 3cm the W.H.O. Implied
Active phase diagnosis at 3cm in all women without reference
to the degree of effacement and particularly that the more
parous women required more than 3cm cervical dilatation
before Active phase could be diagnosed.
Comments on the modified A.M.L. Protocol
The most common problem which did not allow for comparable
results amongst those who chose to modify is difficulty with
the diagnosis of active phase labour which marks when to
commence A.M.L.
-Recently W.H.O. since 2001 produced a New partograph in which
several of these problems have been remove viz:
(f) The new partograph does not provide space to record the
latent phase.
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CONTD
Management of all parturient in active phase labour focused on the
identification of cervical dilatation rate through regular VE at
some specific interval with the emphasis that a cervical dilatation
rate of 1cm per hour is the standard progress for safe delivery of
the mother of healthy baby within 12 hour
-In the original design the VE was performed at hourly interval
aiming for early diagnosis of progress less than 1cm per hour and
immediate oxytocin augmentation to correct this anomaly with
excellent result of low prolonged labour. C.S. rate and contented
mother with healthy babies but with high augmentation rate and
cost.
-Because of the high cost constraint A.M.L have been practiced
with modified protocol in which the principle have been
maintained but with less frequent VE and delay before instituting
oxytocin augmentation for confirmed cervical dilatation progress
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CONTD
Less than 1cm per hour. The results of such modified protocol are
also excellent but not the same as was achieved with the Dublin
protocol.
-The current practice of A.M.L. is to adapt the principle to suit local
needs and situation so long as the basic tenets are maintained so
much is understood in the concept and principles of A.M.L. that it is
now easily defined as the strategic approach to the management of
spontaneous labour (already established in active phase) aimed at
the prevention of prolonged labour based on the anticipation of
normal progress at the cervical dilatation role of 1cm per hour as
the basis to achieve safe delivery of a mother of a healthy baby
within 12 hours.
Active Management of Labour of the UBTH
As by the review of the obstetric data in 1991 the main problem
was prolonged labour rate of 33% especially in the primigravida in

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Whom the primary C.S. was mainly for spontaneous prolonged
labour and repeat c/s was the 2nd commonest indication for c/s.
In depth analysis revealed that although A.M.L. was being
practiced, it was poorly conceptualized, hap hazardly implemented
and in some cases A.M.L. was commenced on the latent phase
labour.
(b) The difficult problem cases were often not brought early
enough the attention of the more senior staff with the appropriate
knowledge to deal with the cases.
© The use to which which each aspect of the Partograph which is
the tool for implementing A.M.L. should be put was not clearly
defined and known to each cadre of staff whether midwives, junior
or senior obstetric staff. Hence the partograph was not a very useful
too to facilitate the A.M.L.
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CONTD
Strategy for the A.M.L. UBTH
(3) Evolve clear cut parameter for the diagnosis of Active phase
labour to mark the commencement of A.M.L. and eliminate the
initiation of A.M.L. in the latent phase.
(4) Because of the constraints in manpower and restrictive supply
of consumables a team work approach was evolved which
incorporated all obstetric and midwifery staff in a
complimentary role in the management of spontaneous Active
phase labour using the Partograph to achieve the followings:
(e) The parturients with active phase problems who are the longer
staying patients in the labour ward are progressively
transferred to the care of the move senior obstetricians from
the junior staff.
(f) The further management of the longer staying patient and more
difficult cases and all decision for c/s must involve the senior

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Registrar in consultation with the consultant on call.
© All labour ward and entire department staff are exposed to
the details of the protocol through review of all cases
managed daily at the departmental morning meetings.
The Protocol is as follows:
(5) All women at term confirmed to be in Active phase labour
have an ARM performed except there were contra indication
like footing breech or occult cord presentation. All details are
recorded on the partograph
(6) The cervical os dilatation at the admission is used to construct
the individualized Alert line based on – slope of 1cm per hour
till delivery and the Action line was drawn as well 2 hours to
the right and parallel to the individualized Alert line.

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CONTD
• The next VE was performed after 4 hours and plotted on the
partograph and subsequent VE repeated every 2 hours till
delivery. The progress was interpreted with reference to the
Alert and Action line.
• No junior obstetric staff (midwife, House officer or S.H.O.) is
allowed to perform more than 2 VE at (2-4) hours apart on any
woman in Active phase labour. The need for the 3rd VE by the
same junior staff is the indication to invite the more senior
obstetric staff
• When the cervical dilatation graph touch the Alert line, the
midwife must call the Doctor or the House officer, S.H.O. must
call the Registrar etc to perform the next VE assessment.
• When the cervical dilatation graph touch or cross the Action
line, the Registrar or Senior Registrar must be informed to
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CONTD
assess and define the cause of the delay at the next VE 2 hour
apart maximum
3. Oxytocin augmentation is only performed when the cervical
dilatation graph cross the action line and VE by a Senior staff
has excluded C.P.D.
4. Oxytocin augmentation is performed only for a duration of 8
hours with VE assessment at 2 hourly intervals.
5. Any further VE in a woman whose progress has crossed the
Action line for over 2 hours must be performed by the Senior
Registrar or Consultant.
6. All decision for C/S is taken at the level of the SR in
consultation with the consultant on call.
7. A nurse is assigned throughout to any woman on oxytocin
augmentation.
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CONTD
2. All deliveries are recorded on an obstetric data sheet and
reviewed every morning with all members of staff in the
department (Nurses and Doctors) present to assess compliance
to the protocol.

Results
Analysis of data was performed in 1998 – 2000 viz:
6. Prolonged labour was reduced from 33% to 1%
7. C/S rate was reduced to 6% from the 28% in 1991
8. The oxytocin argumentation rate rate was 24%
9. Vaginal deliver rate was 90% from the previous 82%
10. The perinatal mortality rate was 43/1000 from the previous
87/1000.
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CONCLUSION
This A.M.L. protocol is an excellent example of the adaptation of
the principles of A.M.L. for local needs and in line with
available resources. Viz
d) It did not require senior obstetric staff to be involved in the
diagnosis of Active phase but the Senior staff were later
mandatory involved if the cases because difficult and staying
longer in labour ward. This is commendable rational use of the
source Senior obstetric staff manpower.
f) It did not require VE every hourly but (2-4) hourly
g) It did not augment labour as soon as slow labour progress was
diagnosed when the Alert line was crossed but only 2 hour later
which objectified augmentation only for the proven cases of
labour dystocia.

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b. Like the Dublin protocol for A.M.L. the UBTH protocol
relied on A.R.M early in the Active phase and aimed to
prevent prolonged labour based on the anticipation of labour
progress at the normal rate of 1cm per hour until delivery.
c. The outcome of 1% prolonged labour rate and 6% c/s rate is
an excellent achievements.
RECOMMENDATION
This format which is a substantial modification of the original
A.M.L. protocol from Dublin Ireland take care of the
constraints in our environment and is recommended for
adoption for the practice of A.M.L. the Resource poor areas
of the world.

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