MECHANISM OF LABOUR AND PARTOGRAPH Ms.A.

JALAJARANI Mechanism of labour Definition Mechanism of labour is the series of passive movements of the fetus during its passage through the maternal pelvis during labour. Principles of Mechanism of Labour Descent takes place throughout labour Whichever part leads and first meets the resistance of the pelvic floor will rotate forward until it comes under the symphysis pubis Whatever emerges from the pelvis will pivot around the pubic bone.

LEFT OCCIPITO ANTERIOR (LOA)-Normal Labour Lie : Longitudinal Presentation : Vertex Position : LOA Attitude : Flexion Denominator : Occiput Presenting part: Posterior part of the right parietal bone. Engagement of Head When the foetal head enters the pelvic brim, the occiput lies to the left ileopectineal eminence, sinsiput at right sacroiliac joint and sajital suture lies on right oblique diameter of the maternal pelvis. The engaging anteroposterior diameter of head is either suboccipito bregmatic 9.5cm or suboccipitifrontal 10cm.the engaging transverse diameter is biparietal 9.5cm Descent Descent is the continuous process which takes place due to forceful uterine contraction and retraction, rupture of membranes, complete cervical dilatation and maternal efforts. Flexion Flexion is increased throughout labour. When the head meets the resistance of the pelvic floor flexion is increased. The increased flexion will decrease the presenting diameter ie. sub occipito-frontal (10cm) to a smaller diameter suboccipito-bregmatic (9.5cm). The occiput becomes the leading part. Internal rotation of the head As the descent keeps on taking place, occiput leads and meets the pelvic floor first and rotates anteriorly 1/8th of the circle to come under the symphysis pubis. The anteroposterior diameter of the head now lies in the anteroposterior diameter of the pelvic outlet.

Crowning The occiput slips beneath the subpubic arch and crowning occurs when the head no longer recedes back between the contractions and the widest transverse diameter (biparietal) is born. Extension of the head The fetal head pivots around the pubic bone while the sinciput, face and chin sweep the perineum and head is born by the movement of extension. Restitution The twist in the neck of the fetus that resulted from internal rotation is now corrected by a slight untwisting movement. The occiput moves 1/8th of the circle towards the side from which it started. Internal rotation of the shoulders The anterior shoulder reaches the pelvic floor first in the left oblique diameter and rotates forward 1/8th of the circle from right to left and thus the shoulders are now in the AP diameter of the pelvis. External rotation of the shoulders It takes place simultaneously with internal rotation of the shoulders and the occiput of the fetal head now lies laterally facing mothers right thigh. Birth of shoulder and trunk As the descent taking place continuously, the anterior shoulder escapes under the symphysis pubis, posterior shoulder sweeps the perineum and body is born by the movement of lateral flexion. PARTOGRAPH Friedman's partograph devised in 1954 was based on observations of cervical dilatation and fetal station against time elapsed in hours from onset of labour. The time onset of labour was based on the patient's subjective perception of her contractility. A partograph is a graphical record of the observations made of women in labour. The partograph is a tool for the management of labor. It is a printed graph representing the stages of labor on which a record of all observations and interventions are plotted. A partograph is started for all patients who enter for a trial of labor. The normal progress in active labor is assessed by the descent of the baby, the dilatation of the cervix, fetal heart rate, color of the amniotic fluid, the presence of moulding, the pattern of uterine contraction, general condition of the mother and the medications that have been given to mother. Already plotted on each printed partograph are an alert line and an action line. The alert line is plotted to correspond with the onset of the active phase of labor. When the womans cervix reaches 3 to 4 cm, the provider should expect dilatation to continue at about the rate of 1 cm per hour.

The action line is plotted 4 hours after the alert line. If the womans labor is not following the expected course after 4 hours, the plot of her labor will begin to approach the action line, signaling the need to take action. Interventions that may be appropriate when the action line is crossed include the use of oxytocin to augment labor, vacuum assisted birth (if the cervix is fully dilated), or caesarean section. Objectives early detection of abnormal progress of a labour prevention of prolonged labour recognize cephalopelvic disproportion long before obstructed labour assist in early decision on transfer , augmentation , or termination of labour increase the quality and regularity of all observations of mother and fetus early recognition of maternal or fetal problems the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc.).

WHO partograph The partograph has been modified to make it simpler and easier to use. The latent phase has been removed. Plotting on the partograph begins in the active phase when the cervix is 4 cm dilated. Record the following on the partograph: The components of a partograph are: Patient identification - name, gravida, para, and hospital number, date and time of admission and time of rupture of membranes. Time recorded at hourly interval. Fetal heart rate - Record every half hour State of membranes and color of liquor: to mark I for intact membranes, C for clear, and M for meconium stained liquor, B for blood stained liquor Moulding: Space between two bones Sutures apposed Sutures overlapped but reducible Sutures overlapped and not reducible Cervical dilatation Assessed at every vaginal examination and marked with a cross (*). Begin plotting on the partograph at 4 cm. Alert line: A line that starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour. Action line: Parallel and 4 hours to the right of the alert line.

Descent assessed -It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement. The rule of fifth means the palpable fifth of the fetal head are felt by abdominal examination to be above the level of symphysis pubis. When 2/5 or less of fetal head is felt above the level of symphysis pubis , this means that the head is engage , and by vaginal examination , the lowest part of vertex has passed or is at the level of ischial spines Assessing descent of the fetal head by vaginal examination; 0 station is at the level of the ischial spine (Sp). The distance of the presenting part above (-3,-2,-1) or below the ischial spines (3, 2, 1) Hours: Refers to the time elapsed since the onset of the active phase of labor. Time: Record actual time. Uterine contractions- the squares in the vertical columns are shaded according to duration and intensity. Chart every half hour; palpate the number of contractions in 10 min and their duration in seconds. Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase. Each square represents one contraction Less than 20 contractions per seconds. Between 20 and 40 contractions per seconds. More than 40 contractions per seconds.

Drugs and fluids. Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30 minutes. Oxytocin concentration in the upper box and dose (m IU/min) in the lower box. Urine analysis- Protein, acetone and volume- Record every time urine is passed Temperature record. Pulse: Record every 30 minutes and mark with a dot ()

Advantages of partograph: Useful tool in labor room. Influences obstetric decision making. A useful training tool. Improves quality of maternity services. mortality audit. In addition, it is a useful aid in maternal

 As the medico legal aspects of medicine become more prominent there is an increasing need for better record keeping. The partograph ensures that a detailed record of the progress of labor is kept. A single sheet of paper can provide details of necessary information at a glance. No need to record labor events repeatedly. It can predict deviation from normal duration of labor early. So appropriate steps could be taken in time. It facilitates handover procedure. Introduction of partograph in the management of labor has reduced the incidence of prolonged labor and caesarean section rate. There is improvement in maternal morbidity, perinatal morbidity and mortality. USING THE PARTOGRAPH- POINTS TO REMEMBER It is important to realize that the partograph is a tool for managing labor progress only The partograph does not help to identify other risk factors that may have been present before labor started only start a partograph when you have checked that there are no complications of pregnancy that require immediate action a partograph chart must only be started when a woman is in labor,-- be sure that she is contracting enough to start a partograph if progress of labor is satisfactory , the plotting of cervical dilatation will remain or to the left of the alert line when labor progress well , the dilatation should not move to the right of the alert line the latent phase. 0 3 cm dilatation, is accompanied by gradual shortening of cervix. normally , the latent phase should not last more than 8 hours the active phase , 3 10 cm dilatation , should progress at rate of at least 1 cm/hour when admission takes place in the active phase , the admission dilatation, is immediately plotted on the alert line when labor goes from latent to active phase , plotting of the dilatation is immediately transferred from the latent phase area to the alert line dilatation of the cervix is plotted ( recorded with an X , descent of the fetal head is plotted with an O , and uterine contractions are plotted with differential shading descent of the head should always be assessed by abdominal examination ( by the rule of fifths felt above the pelvic brim ) immediately before doing a vaginal examination assessing descent of the head assists in detecting progress of labor increased molding with a high head is a sign of cephalopelvic disproportion vaginal examination should be performed infrequently as this is compatible with safe practice ( once every 4 hours is recommended )

 when the woman arrives in the latent phase , time of admission is 0 time a woman whose cervical dilatation moves to the right of the alert line must be transferred and managed in an institution with adequate facilities for obstetric intervention , unless delivery is near when a woman ,s partograph reaches the action line , she must be carefully reassessed to determine why there is lack of progress , and a decision must be made on further management ( usually by an obstetrician or resident ) when a woman in labor passes the latent phase in less than 8 hours i.e., transfers from latent to active phase , the most important feature is to transfer plotting of cervical dilatation to the alert line using the letters TR, Leaving the area between the transferred recording blank. The broken transfer line is not part of the process of labor do not forget to transfer all other findings vertically