INTRAPARTUM

ASSESMENT
DR MASUMA ABBAS
MONITORING DURING LABOUR
Do not offer cardiotocography to women at low risk of complications in established labour.
Offer intermittent auscultation of the fetal heart rate to women at low risk of complications in established first stage
of labor:
Use either a Pinard stethoscope or doppler ultrasound.
Carry out intermittent auscultation immediately after a contraction for at least 1 minute, at least every 15 minutes,
and record it as a single rate.
Record accelerations and decelerations if heard.
Palpate the maternal pulse hourly, or more often if there are any concerns, to differentiate between the maternal and
fetal heartbeats.
 If there is a rising baseline fetal heart rate or decelerations are suspected on intermittent auscultation,
actions should include:

carrying out intermittent auscultation more frequently, for example after 3 consecutive contractions
initially

thinking about the whole clinical picture, including the woman's position and hydration, the strength and
frequency of contractions and maternal observations.
 If a rising baseline or decelerations are confirmed, further actions should include:

summoning help

advising continuous cardiotocography, and explaining to the woman and her birth
companion(s) why it is needed

transferring the woman to obstetric-led care, provided that it is safe and appropriate to do so.
 Do not offer continuous cardiotocography to women who have non-significant meconium if
there are no other risk factors.
Do not regard amniotomy alone for suspected delay in the established first stage of labour as
an indication to start continuous cardiotocography.
 Address any concerns that the woman has about continuous cardiotocography, and give her and her birth
companion(s) the following information:

Explain that continuous cardiotocography is used to monitor the baby's heartbeat and the labour contractions.

Explain that it may restrict her mobility.

Give details of the types of findings that may occur. Explain that a normal trace indicates that the baby is coping well
with labour.

Explain that changes to the baby's heart rate pattern during labour are common and do not necessarily cause
concern.

Explain that if the trace is not normal, there will be less certainty about the condition of the baby and so continuous
monitoring will be advised.

Explain that decisions about her care during labour and birth will be based on an assessment of several factors,
including her preferences, her condition and that of her baby, as well as the findings from cardiotocography.
 If continuous cardiotocography has been started because of concerns arising from intermittent
auscultation, but the trace is normal after 20 minutes, return to intermittent auscultation
unless the woman asks to stay on continuous cardiotocography.
A DVISE CONT INUO US CA R DI O T OCO GRAPH Y I F A NY O F T H E FO L LO W ING R I SK FA CT O R S
A R E P R ESENT AT I NI T I A L A SSESSM ENT (SEE SECT I O N 1 . 4) O R A R I SE DUR I NG L A B O UR :

maternal pulse over 120 beats/minute on 2 occasions 30 minutes apart

temperature of 38C or above on a single reading, or 37.5C or above on 2 consecutive

occasions 1 hour apart

suspected chorioamnionitis or sepsis

pain reported by the woman that differs from the pain normally associated with contractions

the presence of significant meconium

 fresh vaginal bleeding that develops in labour

severe hypertension: a single reading of either systolic blood pressure of 160 mmHg or more or diastolic
blood pressure of 110 mmHg or more, measured between contractions

hypertension: either systolic blood pressure of 140 mmHg or more or diastolic blood pressure of 90
mmHg or more on 2 consecutive readings taken 30 minutes apart, measured between contractions

a reading of 2+ of protein on urinalysis and a single reading of either raised systolic blood pressure (140
mmHg or more) or raised diastolic blood pressure (90 mmHg or more)

confirmed delay in the first or second stage of labour

contractions that last longer than 60 seconds (hypertonus), or more than 5 contractions in 10 minutes
(tachysystole)

oxytocin use.
INTERPRETATION OF
CARDIOTOCOGRAPH TRACES
Principles for intrapartum CTG trace interpretation
When reviewing the CTG trace, assess and document contractions and all 4 features of fetal
heart rate: baseline rate; baseline variability; presence or absence of decelerations (and
concerning characteristics of variable decelerations* if present); presence of accelerations.
If there is a stable baseline fetal heart rate between 110 and 160 beats/minute and normal
variability, continue usual care as the risk of fetal acidosis is low. If it is difficult to categorise or
interpret a CTG trace, obtain a review by a senior midwife or a senior obstetrician.
Accelerations
The presence of fetal heart rate accelerations, even with reduced baseline variability, is
generally a sign that the baby is healthy.
Do not use maternal facial oxygen therapy for intrauterine fetal resuscitation, because it may harm the baby
(but it can be used where it is administered for maternal indications such as hypoxia or as part of
preoxygenation before a potential anaesthetic).
Do not offer amnioinfusion for intrauterine fetal resuscitation.
If the cardiotocograph trace is pathological, offer digital fetal scalp stimulation. If this leads to an acceleration
in fetal heart rate, only continue with fetal blood sampling if the cardiotocograph trace is still pathological.
If digital fetal scalp stimulation (during vaginal examination) leads to an acceleration in fetal heart rate, regard
this as a sign that the baby is healthy. Take this into account when reviewing the whole clinical picture.
PHYSIOLOGY OF FETAL HEART RATE
DECELERATIONS
 KEY LEARNING POINTS
It is important to remember the following learning points regarding EFM:
it is used to identify intrapartum hypoxia a significant cause of fetal death and disability; fetal hypoxia can lead on to fetal
asphyxia and death
it should not be used unless indicated as it increases the rates of caesarean section and instrumental delivery in low-risk
women
it has become an integral component of labour management in high-risk women.
Fetal hypoxia is a major cause for perinatal death, neonatal morbidity and neurodevelopmental disability. Hypoxic brain
injury or death of the fetus accounts for nearly 38% of claims handled by the Medical Defense Union and Medical
Protection Society in the UK. The effect of hypoxia on the fetal brain is reflected on the changes in fetal heart rate
patterns.
Limitations imposed by the use of continuous EFM:
reduced mobility
possibility that woman will not be the centre of care in labour
increased intervention
variation in interpretation of CTG trace
chorioamnionitis could make interpretation unreliable
litigation; therefore, good record-keeping is crucial.

KEY LEARNING POINTS

Remember...

From 26 weeks onwards, decelerations of the fetal heart should be regarded as abnormal.
Intrauterine infection leads to a rise in perinatal morbidity and mortality and, in this context, the CTG is less sensitive
at detecting hypoxia.
No CTG should be interpreted without a full understanding of the clinical picture.
When hypoxia develops gradually, the first features to be noted are the absence of accelerations, increase in baseline
rate and reduction in baseline variability. The worsening situation may be reflected by the deceleration getting deeper
and wider.
In a non-reactive trace, when the baseline variability is less than 5 beats/minute, shallow decelerations of less than 15
beats may indicate an ominous pattern.
Head compression and true cord compressions are associated with activation of the parasympathetic nervous system
and, hence, result in early and variable decelerations, respectively, both of which are short-lasting.
CTG INTERPRETATION AND FURTHER
MANAGEMENT
If CTG is normal: continue CTG or if it was started because of concerns arising from intermittent auscultation,
remove CTG after 20 minutes if there are no non-reassuring/abnormal features and no ongoing risk factors.

Describe decelerations as 'early', 'variable' or 'late'. Do not use the terms 'typical' and 'atypical' because they can
cause confusion.

If non-reassuring: commence conservative measures left lateral position, oral/intravenous fluids, stop
oxytocin, consider tocolysis.

If the CTG is abnormal: Offer to take fetal blood sample (FBS; for lactate or pH) after implementing
conservative measures, or expedite birth if an FBS cannot be obtained and no accelerations are seen as a result of
scalp stimulation.

Inform the consultant obstetrician if any FBS result is abnormal/FBS cannot be obtained or a third FBS is thought
to be needed.
CTG INTERPRETATION AND FURTHER
MANAGEMENT
Lactate (mmol/l) pH Interpretation

4.1 7.25 Normal

4.24.8 7.217.24 Borderline

4.9 7.20 Abnormal

CTG INTERPRETATION AND FURTHER
MANAGEMENT
To reduce false-positives and, consequently, unnecessary caesarean sections, fetal scalp pH
sampling is recommended for cases with suspicious or pathological traces in labour (except in
cases of prolonged deceleration where immediate delivery may be warranted).
Remember the 'Rule of 3' for fetal bradycardia:
3 minutes call for help
6 minutes move to theatre
9 minutes prepare for assisted delivery
12 minutes aim to deliver the baby.
The pH of the fetus has been shown to drop at the rate of 0.01 every 23 minutes.
CTG INTERPRETATION AND FURTHER
MANAGEMENT
Reasons for the high rates of CTG misinterpretation include:
difficulties in pattern recognition
difficulty interpreting the CTG in the clinical context
poor interobserver agreement on the classification of CTG cases
technical factors, including a faulty leg plate, electrode or monitor, setting the recording rate at 3
cm/minute instead of the standard 1 cm/minute, and the fact that very slow fetal heart rates may
be doubled and very fast rates (>240 beats/minute) may be halved by the machine.
It is important to confirm that the external fetal monitor is actually recording fetal heart rate and
not maternal heart rate (transmitted from a maternal vessel, such as the aorta or uterine artery).
An internal fetal electrode is not definitive, as a fetus that is recently dead can conduct the
maternal cardiac signals through its body to the electrode.
TIME FOR QUESTIONS:
A 30-year-old at 35 weeks of gestation is admitted in spontaneous labor. She is fully dilated. On
examination the head is 0/5 palpable per abdomen, in LOA position with minimal caput and no
moulding. She has made good progress from 3 cm to full dilation in three hours. She has been
pushing for one hour.You are asked to assess the CTG.

Determine the mnemonic (DR C BRAVADO) for this trace:

ANSWER
Determine risk: high risk (preterm).
Contractions: 45 in 10maximal amount, any more would be hyperstimulation.
Baseline rate: 170 bpm. This is best assessed in between a contraction, as the FHR never
goes up during a contraction. If it does, always consider that you may be measuring the
mothers heart rate (non-reassuring).
Accelerations: none (uncertain significance).
Variability: between 510 bpm (reassuring).
Decelerations: Early decelerations are rare and are absent here. They account for around
10% of all decelerations and only ever occur in the second stage/late first stage when the
fetal head is deeply engaged. They, like late decelerations, need to be uniform in size, shape
and timing. Thus they too only account for around 10% of decelerations. Variable
decelerations are far more common (80% of decelerations). Here they are variables
decelerations lasting >60 seconds and dropping >60 beats. Also they occur with over
50% of contractions in a 30-minute segment of trace (abnormal).
Overall impression: pathological (one abnormal and one non-reassuring).
TIME FOR QUESTIONS:
A 35-year-old with an IVF pregnancy is at 42+ weeks of gestation. She has been induced into
labour and had an oxytocin drip for the last six hours.You are asked to assess the CTG at 8 cm
dilation.
ANSWER

Determine risk: high risk (42+ weeks)

Contractions: 45 in 10maximal amount, any more would be hyperstimulation
Baseline rate: 155160 bpm. This is best assessed in between a contraction, as the FHR never goes
up during a contraction. If it does, always consider that you may be measuring the mothers heart
rate (reassuring)
Accelerations: none
Variability: between 510 bpm (reassuring)
Decelerations: variable decelerations, some lasting more than 60 seconds. They occur with over
50% of contractions in a 30-minute segment of trace (abnormal).
Overall impression: pathological (one abnormal and two reassuring).
TIME FOR QUESTIONS
Unfortunately the oxytocin was not stopped, and the labour was allowed to continue because
the trace was erroneously interpreted as having accelerations.
The woman is still 8 cm dilated, head 2/5 palpable per abdomen and left OP position with caput
+++ and moulding ++. She has made a 2 cm progress over the last eight hours.
Again, determine the mnemonic (DR C BRAVADO) for this trace.
ANSWER

Determine risk: high risk (42+ weeks)same as before.

Contractions: 5 in 10with coupling, indicative of hyperstimulation.
Baseline rate: 170 bpm in the first half of the trace, and then dropping to 140 bpm in the second
half of the trace (non-reassuring).
Accelerations: none.
Variability: between 510 bpm (reassuring).
Decelerations: variable decelerations, some lasting more than 60 seconds and are deeper than 60
beats. Also they occur with over 50% of contactions in a 30-minute segment of trace (abnormal).
Overall impression: pathological.
TIME FOR QUESTIONS

A 25-year-old is at 39+ weeks of gestation and been induced for pre-eclampsia. The woman is
now 3 cm dilated after prostaglandin gel six hours ago, and has just undergone an ARM and was
very bloodstained.
You are asked to assess the CTG. Determine the mnemonic (DR C BRAVADO) for this trace:
ANSWER

Determine risk: high risk (pre-eclampsia)

Contractions: none present
Baseline rate: 160 bpm (reassuring)
Variability: between 510 bpm, although in the second half of the trace the variability is
absent/looks preterminal (abnormal)
Decelerations: none are present in the first half of the trace, but the trace becomes
preterminal/sinusoidal after the ARM/after 20 minutes (abnormal)
Overall impression: pathological (two abnormal features)
FETAL BLOOD SAMPLING
 Fetal blood sampling (FBS) should be advised in the presence of a pathological fetal heart rate
(FHR) trace unless there is clear evidence of acute compromise (i.e. immediate delivery is
thought necessary).

Where there is clear evidence of acute fetal compromise (for example, a prolonged
deceleration for more than 3 minutes), FBS should not be undertaken and urgent preparations
to expedite birth should be made.

FBS equipment varies from hospital to hospital, and you should familiarize yourself with the
available kit before proceeding.
INDICATIONS FOR FBS

The indications for FBS include:

pathological CTG in labour (cervix dilated >3 cm)

suspected acidosis in labour (cervix dilated >3 cm).
PREREQUISITES FOR FBS

Before you start an FBS procedure, you must:

explain the procedure to the woman and obtain her verbal consent
confirm the position and dilatation of the cervix (>3 cm), as well as the station of the
presenting part
ensure that the instruments are to hand and that the pH analyser is functioning
ensure there are no contraindications for the procedure.
FBS PROCEDURE

Place the woman either in a lithotomy or left lateral position with her right leg supported and abducted. Then drape the
area around the perineum to provide a sterile field.
Introduce the largest-diameter, lubricated amnioscope that the cervix can accommodate. Direct the amnioscope
posteriorly and sweep it anteriorly to catch the anterior lip of the cervix.
Remove the amnioscopes obturator and attach your light source. Ideally, the cervix should not be visible. Try to visualise
the fetal scalp clearly.
Clean the fetal scalp with a cottonwool ball dipped in sterile water and spray the scalp with ethyl chloride to produce a
reactive hyperaemia.
Apply a thin film of Vaseline with a dental roll to increase surface tension on the fetal scalp; this encourages the
formation of sizeable droplets of blood.
Insert a guarded blade into the scalp to the full depth of the guard. Do not stroke the blade across the scalp as this may
produce a lesion that is too large.
Collect the blood droplet into your capillary tube. At least two samples should be obtained. The second may be taken
while the first is being analysed by an assistant.
Apply pressure to the fetal scalp with cottonwool at the end of the procedure if any bleeding is evident.
Reposition the mother comfortably and explain the results to her with your action plan.
FBS PROCEDURE - VIDEO
INTERPRETATION OF RESULTS
FBS result (pH) Interpretation
7.25 Normal FBS result. Repeat after 1 hour if CTG
remains the same
7.217.24 Borderline FBS result. Repeat after 30 minutes
7.20 Abnormal FBS result. Consider delivery
INTERPRETATION OF RESULTS
These results should be interpreted taking into account the previous pH measurement, the rate of
progress in labour and the clinical features of the woman and baby.

According to the recent NICE Guideline on Intrapartum Care (2014):

if the FBS result is normal, offer repeat sampling no more than 1 hour later if this is still indicated by
the cardiotocograph trace, or sooner if additional non-reassuring or abnormal features are seen
if the FBS result is borderline, offer repeat sampling no more than 30 minutes later if this is still
indicated by the cardiotocograph trace, or sooner if additional non-reassuring or abnormal features are
seen
the time needed to take a FBS should be taken into account when planning repeat sampling
if the cardiotocograph trace remains unchanged and the FBS result is stable (that is pH is unchanged)
after a second test, further samples may be deferred unless additional non-reassuring or abnormal
features are seen
if a FBS is indicated but a sample cannot be obtained and there is no improvement in the
cardiotocograph trace, advise the woman that the birth should be expedited.
CONTRAINDICATIONS

Contraindications include:

maternal infection (e.g. HIV, hepatitis viruses and herpes simplex virus)
fetal bleeding disorders (e.g. haemophilia)
prematurity (birth at less than 34 weeks of gestation)
acute fetal compromise (e.g. prolonged fetal bradycardia of >3 minutes).
QUESTIONS:

You are managing a woman who is 5 cm dilated and showing atypical variable
decelerations on an intrapartum fetal CTG.

Answer whether the following statements are true or false.

Oxytocin dose should be reduced or stopped

Fetal blood sampling should be carried out

An immediate delivery should be conducted in the presence of a grade 1 meconium

QUESTIONS:

A fetal blood sample has a pH of 7.20. The mother now has a thick meconium and the
baby's head is at the perineum.

Answer whether the following statements are true or false.

A repeat FBS should be conducted in 30 minutes

An assisted vaginal delivery should be considered

An immediate delivery by caesarean section should be organised

THE PARTOGRAM

The partogram is a pictorial representation of progress in labor. It is used to alert clinicians to

any problems with labor progress, or with fetal or maternal wellbeing.
Dysfunctional labour can be diagnosed by careful and repeated assessment of the power,
passage and the passenger. The partogram is a means of graphically displaying this intrapartum
information in a clear and focused way and facilitates effective transfer of information.The
partogram has been in use for over 20 years and its use has been shown to be associated with
a reduction in prolonged labour, reduction in the augmentation of labour and a reduction in
sepsis.
USES OF THE PARTOGRAPH

The partograph should be commenced following accurate diagnosis of established labour. The
expected progress in labour is 1 cm/hr although in primigravid women there are fewer
interventions if it is accepted that progress can be 0.5 cm/hr.
An action line of 4 hours should be used, as earlier action lines increase interventions. If
progress is to the right of the action line, then it is considered to be prolonged and action
should be taken. The NICE guidance on caesarean section states that a 4-hour action line
reduces the rate of caesarean sections.
 The WHO partograph begins only in the active phase of labour, when the cervix is 4 cm or more dilated (see
below). However, it is a tool which is only as good as the health-care professional who is using it. The
observations that are recorded will document the following:

O Maternal well-being: record pulse rate every 30 minutes, blood pressure and temperature 4-hourly, urine
output and dipstick testing for protein, ketones (if available) and glucose after voiding, and record all fluids and
drugs administered. If the findings become abnormal, increased frequency of observation and testing will be
required, and intervention may be implemented.

O Fetal well-being: record fetal heart rate for 1 minute every 1530 minutes after a contraction in the first
stage, and every 5 minutes in the second stage. If abnormalities are noted, urgent delivery can be considered.

O Liquor: clear, meconium stained (thick or thin), bloody or absent. Thick meconium suggests fetal distress, and
closer monitoring of the fetus is indicated. Check every 30 minutes.

O Frequency, duration and strength of uterine contractions (assessed by palpation): record every 30 minutes.

O Abdominal examination: to assess descent of the fetal head.

How to record contraction frequency and length.
The number of squares filled in records the
number of contractions in 10 minutes. The shading
shows the length of contractions.
 O Vaginal examination: this should be done no less than every 4 hours to assess cervical
dilatation, descent of the fetal head, and moulding of skull bones. More frequent examination is
only undertaken if indicated.
 O Moulding: 0 = bones are separated and sutures can be easily felt; + 1 = bones are just touching
each other; + 2 = bones are overlapping but can be reduced; + 3 = bones are severely overlapping
and irreducible.

O Cervical dilatation: assess at each VE and mark with a cross . Begin at 4 cm.

O Alert line: starting at 4 cm of cervical dilatation, up to the point of expected full dilatation at the
rate of 1 cm per hour.

O Action line: parallel and 4 hours to the right of the alert line.

O Descent assessed by abdominal palpation: this refers to the part of the head (which is divided
into five parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal
examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis.

O Hours: this refers to the time elapsed since the onset of the active phase of labour (observed or
extrapolated).
 O Time: record the actual time at 30-minute intervals.

O Contractions: chart every 30 minutes; palpate the number of contractions in 10 minutes and their duration
in seconds (< 20 seconds, 2040 seconds, > 40 seconds).

O Oxytocin: record the amount (in units) of oxytocin per volume of IV fluids, and the number of drops per
minute, every 30 minutes when used.

O Drugs given: record any additional drugs given.

O Pulse: record every 30 minutes and mark with a dot (). O Blood pressure: record every 4 hours and mark
with arrows, unless the patient has a hypertensive disorder or pre-eclampsia, in which case record every 30
minutes.

O Temperature: record every 4 hours.

O Urine, ketones and volume: ideally record every time urine is passed.
DEGREES OF MOULDING OF THE BONES OF
THE FETAL SKULL.

Increasing moulding may be a sign of cephalo-pelvic

disproportion, as the fetal skull bones overlap to aid
passage through the maternal pelvis.

Key: 0 = bones are separated and sutures can be easily

felt, + = bones are just touching each other, ++ = bones
are overlapping but can be reduced, +++ = bones are
severely overlapping and irreducible.
DETAILS OF THE POWER

Frequency of contractions number of contractions occurring over a 10 minute period are

recorded and plotted
Duration of contractions effective uterine activity is generally sustained for a period greater
than 40 seconds
Amplitude this is an assessment of the perceived strength of contractions. It must be
stressed that this is a very subjective assessment. The intensity of uterine contractions can only
be accurately defined by the placement of an intrauterine pressure catheter. The value of
formal intrauterine pressure monitoring is limited.
DETAILS OF THE PASSENGER
Fetal heart rate recording listening to the fetal heart following a contraction every 15 minutes for a period of one minute during the
first stage. The fetal heart rate should be recorded after each expulsive contraction during the second stage
Station
Position count the number of sutures: three around the posterior fontanelles and four around the anterior fontanelles
Moulding this refers to changes in relationship between skull bones
Three degrees of moulding are noted:

1+ suture lines touch

2+ suture lines overlap and are reducible
3+ suture lines overlap and are irreducible

Ideally, the degree of moulding should be assessed across two separate suture lines and scores are added producing a score out of six.

Application to the cervix

Caput formation.
DETAILS OF THE PASSAGES: CERVIX

Effacement
Dilatation
Pelvic anatomy.
Clinical pelvimetry is a means of assessing pelvic capacity through a vaginal examination.
Unfavourable factors that may be detected include prominence of the ischial spines
(interspinous width) or prominence of the ischial tuberosity (intratuberous width), narrow
subpubic angle (if this is less than 90 degrees the diameter of the outlet may be reduced),
proximity of the sacrum to the pubis symphysis (can you reach the sacrum with ease). Clinical
pelvimetry is subjective and results must be interpreted with caution.
PARTOGRAPH ASSESSMENT 1

1) Describe the shape of the line

2) What does the shape of the line tell you

about the progression of labour?

3) How would you manage this situation?

 1) Describe the shape of the line.

Answer: The line of cervical dilation is flat.

2) What does the shape of the line tell you about the progression of labour?

Answer: This indicates a delay in the first stage of labour.

3) How would you manage this situation?

Answer: You need to manage this delay in labour in order to increase uterine contractions. You
could give intravenous oxytocin (Syntocinon), but this needs to be used with caution in a
multiparous woman because of the risk of uterine rupture.

The partogram below shows the effect of giving Syntocinon. With increased frequency and strength
of contractions, progress is normal and a vaginal delivery resulted.
What would you do now?
 Following administration of intravenous Syntocinon there was no increase in cervical
dilatation. What would you do now?

Answer: This suggests cephalopelvic disproportion and a caesarean section should be

performed.
NORMAL PARTOGRAM
A 36-year-old para 1 presents to the maternity unit
in spontaneous labour at term. In her previous
pregnancy she had a ventouse (vacuum) delivery of
a 3.32 kg baby. On admission to the unit she is 3 cm
dilated. She is contracting 4 in 10 minutes and her
contractions are assessed as moderate.

Two hours later, the vaginal examination is repeated

and her cervix is 4 cm dilated. She is encouraged to
mobilise and her membranes are left intact. Four
hours later she has a spontaneous rupture of the
fetal membranes.

She is now 8 cm dilated. Three hours later she

reports an urge to push on examination her
cervix is fully dilated with the fetal vertex below the
ischial spines, in an occipitoanterior position. Thirty
minutes later she has a spontaneous vertex delivery
DELAY IN THE SECOND STAGE
A 36-year-old para 0 (primigravida) presents to the
maternity unit in spontaneous labour at term. On
admission to the unit she is 3 cm dilated.

She is contracting 4 in 10 minutes and her contractions

are assessed as moderate. Two hours later the vaginal
examination is repeated and her cervix is 4 cm dilated.
She is encouraged to mobilise and her membranes are
left intact.

Four hours later she has a spontaneous rupture of the

fetal membranes. She is now 8 cm dilated. Three hours
later she is reassessed and is found to be fully dilated.
 You are the speciality trainee on call in the labour ward. What information do you want to
know from the midwife who is attending the woman and who undertook the vaginal
examinations?
 From the midwife attending the woman, you would want to know:

is the woman contracting well?

does she have adequate pain relief?
is the assessment of the fetal heart rate reassuring?
is there any fetal head palpable per abdomen?
what is the position of the fetal head?
what is the station of the fetal head?
is there evidence of caput or moulding?
In this case the attending midwife tells you that:

the fetal head is in an occipitoposterior position with the presenting part at the ischial spines
there is no evidence of obstruction (caput or moulding)
there is one-fifth of fetal head palpable per abdomen
the woman is contracting well and the decision is made to repeat the vaginal examination to assess
for progress in two hours' time.
 Critically appraise this woman's management.

Answer:

The management could be justified as she has made good progress so far
Some clinicians would advocate the use of a oxytocin infusion to augment uterine contractions
in a primigravid woman with an OP position
It perhaps would be better to reassess the woman in one hour if there is no progress, then
oxytocin can be commenced.
 The woman is reassessed two hours later and the clinical findings are essentially unchanged apart
from the presence of some caput and moulding.

An oxytocin infusion is commenced and she is examined an hour later.

The presenting part is now at 0+1 and there is no head palpable per abdomen. The degree of caput
and moulding is greater.

She is taken to the delivery theatre where she is delivered by Kielland's rotational mid-cavity
forceps by an experienced doctor.
DELAY IN THE FIRST STAGE OF
LABOUR
A 36-year-old para 1 presents to the maternity unit in
spontaneous labour at term. In her previous pregnancy, she had
a ventouse (vacuum) delivery of a 3.32 kg baby.

On admission to the unit, she is 3 cm dilated. She is contracting

4 in 10 minutes and her contractions are assessed as moderate.
Three hours later the vaginal examination is repeated and her
cervix is 5 cm dilated.

She is encouraged to mobilise and her membranes are left

intact. Four hours later she has a spontaneous rupture of the
fetal membranes. She is now 7 cm dilated. Four hours later she
is assessed again and the findings are unchanged (7 cm dilated).
 You are the specialty trainee on call in labour ward. What information do you want to know
from the midwife who is attending the woman and who undertook the vaginal examinations?
 From the attending midwife you would want to know:

does she have adequate pain relief?

is the assessment of the fetal heart rate reassuring?
how much of the fetal head, if any, is palpable per abdomen?
what is the position of the fetal head?
what is the station of the fetal head?
is there evidence of caput or moulding?
The attending midwife tells you that:

the woman is contracting well and has requested an epidural

the fetal heart rate (CTG) shows no abnormalities
there is two-fifths of the fetal head palpable per abdomen
the fetal head is in an occipitoanterior position and there is caput but no moulding.
 Critically appraise this woman's management and review your answers on the following page.

Answer:

If the woman was a primigravida, you would want to commence an intravenous infusion of oxytocin
(bearing in mind that incoordinate uterine activity is common in the primigravid labour)
Most clinicians would be reluctant to employ oxytocin in parous women who show signs of
obstruction especially if they are considered to be contracting well
The findings are suggestive of cephalopelvic disproportion and the woman is delivered by
caesarean section she has a male infant, born in good condition and weighing 4.7 kg.
THE DIAGNOSIS OF LABOUR
A 17-year-old primigravida presents to the maternity unit at 39
weeks of gestation with painful uterine activity. Her cervix is 3
cm dilated. She believes she is in labour, is distressed and
requests an epidural. The epidural is sited.

Four hours after admission she is reassessed her cervix is

still 3 cm dilated, and an artificial rupture of the fetal
membranes is performed. Four hours later her cervix remains
unchanged and an oxytocin infusion is commenced.

Four hours later, her cervix is still 4 cm dilated and the fetal
head is said to be 'poorly applied'. She is tired, upset and
frustrated. She demands a caesarean section and this is
performed.
 Would you manage her 'labour' differently, and if so, how?
 A 36-year-old para 3 attends your clinic for postnatal review. She gave birth 6 weeks ago and has a number of
concerns about the delivery.

She had presented to the maternity unit at 39 weeks of gestation reporting increasingly regular uterine contractions.
It was noted that she had two normal vaginal deliveries in the past. On examination, uterine activity was palpated ('2 in
10') and the fetal head was 3/5 palpable per abdomen. The cervix was effaced and 3 cm dilated. An admission CTG was
reported as reactive.

She was admitted to the labour ward, confined to a bed and continuous electronic fetal heart rate monitoring was
commenced. Her husband had to go home to arrange childcare for their other children. She was reassessed 1 hour
later and her cervix was unchanged. An artificial rupture of the fetal membranes was performed and she was
commenced on an intravenous infusion of synthetic oxytocin (Syntocinon).

She subsequently developed decelerations on the CTG tracing and 1 hour later was reassessed again, with a view to
performing fetal scalp blood samples (FBS). On examination, her cervix was 9 cm dilated with the fetal head at station
01, in an occipital-transverse position. The FBS results were pH 7.19 and 7.20.

By the end of the procedure, her cervix was fully dilated and she had a ventouse delivery, without analgesia, of a live
male infant. Her husband returned from arranging childcare, just after the baby was born.

Review this womans intrapartum care and critically appraise each intervention. What could have been done
differently?
 An admission CTG should not have been performed (see the NICE guideline on Intrapartum Care) as she was a low-risk pregnancy.
Admission CTGs have been associated with increased likelihood of epidurals, continuous CTG and FBS.

This woman did not need to be admitted to labour ward, as by definition she was not yet in active labour (not yet 4 cm dilated). If she
was too sore or too far from home, she could have been offered admission to an antenatal ward for analgesia, with a plan to reassess at
a set time if no signs of established labour, or as required.

When she was admitted to labour ward she was confined to a bed. The woman should have been encouraged to take up whatever
position she found most comfortable in the first stage of labour. There is evidence that walking and upright positions in the first stage
reduce the length of labour and do not seem to be associated with increased intervention or negative effects on maternal and fetal
wellbeing (Lawrence et al 2009).

Following admission to the labour ward, the woman was commenced on continuous electronic fetal heart rate monitoring (EFM).
Continuous EFM compared with intermittent fetal heart rate auscultation during labour is associated with a reduction in neonatal
seizures, but no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal wellbeing.

However, continuous EFM was associated with an increase in caesarean sections and instrumental vaginal births. The woman should
have been allowed to make an informed choice regarding the method of fetal monitoring to be used during labour (Alfirevic et al 2006).

If she had been admitted to the antenatal ward as opposed to labour ward, she could have been left to establish in labour, as opposed
to the intervention that followed. Subsequently, this may have given her husband adequate time to arrange childcare and then be
present thereafter to offer support when she established in labour. Studies have shown that continuous intrapartum support was
associated with greater benefits when the provider was not a member of the hospital staff, when it began early in labour, and in settings
in which epidural analgesia was not routinely available. These women were likely to have a slightly shorter labour, have a spontaneous
vaginal birth and less likely to have intrapartum analgesia or to report dissatisfaction with their childbirth experiences (Hodnett et al
2009).
 In the absence of concerns regarding maternal or fetal wellbeing, she should not have been reassessed after only 1 hour. The World Health
Organization's Principles of Perinatal Care (Chalmers et al 2001) recommend that four-hourly vaginal examinations during normal labour are
adequate.

This woman had an ARM peformed at 3 cm dilatation. She was probably not in labour and the ARM was therefore not indicated. Further, a
Cochrane review recommends that ARM should not be introduced routinely as part of standard labour management and care (Smyth et al 2007).

The use of an infusion of oxytocin immediately after ARM in parous women is controversial. When employed, it should be used cautiously in
women who are already contracting, as overzealous use may lead to hyperstimulation and subsequent fetal distress, or even uterine rupture.

The decelerations on the CTG may well have been due to hyperstimulation caused by the oxytocin. If this were the case, the oxytocin infusion
should have been stopped and this may have rectified the problem. She had progressed very rapidly in labour (from 3 cm to 9 cm in 1 hour), and
it is likely that even if the oxytocin was stopped, she would have progressed to full dilatation quickly.

The FBS samples were abnormal, necessitating delivery, therefore the use of ventouse was not unreasonable to expedite delivery, assuming all
preconditions for an assisted vaginal delivery have been met (see the StratOG tutorial on Sequelae of hypoxia).

If a ventouse has to be performed expeditiously (because of concerns surrounding fetal wellbeing), no additional analgesia may be required,
although an attempt could be made to infiltrate the perineum with local anaesthetic for comfort (see the StratOG tutorial on Sequelae of
hypoxia). For forceps delivery, ideally a pudendal block should be given.

Appropriate debriefing of the couple after the birth should have taken place, to answer any immediate questions or concerns.