Care in Normal Birth (WHO, 1996, 60 p.): 3. CARE DURING THE FIRST STAGE OF LABOUR: 3.4 Monitoring the Progress of Labour

Care in Normal Birth (WHO, 1996, 60 p.)

(introduction...)

ACKNOWLEDGEMENTS

1. INTRODUCTION

1.1 Preamble

1.2 Background

1.3 Risk Approach in Maternity Care

1.4 Definition of Normal Birth

1.5 Aim of the Care in Normal Birth, Tasks of the Caregiver

1.6 The Caregiver in Normal Birth

2. GENERAL ASPECTS OF CARE IN LABOUR

2.1 Assessing the Well-being of the Woman during Labour

2.2 Routine Procedures

2.3 Nutrition

2.4 Place of Birth

2.5 Support in Childbirth

2.6 Labour Pain

(introduction...)

2.6.1 Non-pharmacological methods of pain relief

2.6.2 Pharmacological pain relief in labour

2.7 Monitoring the Fetus during Labour

(introduction...)

2.7.1 Assessment of amniotic fluid

2.7.2 Monitoring the fetal heart rate

2.7.3 Fetal scalp blood examination

2.7.4 Comparison of auscultation and electronic fetal monitoring

2.8 Cleanliness

3. CARE DURING THE FIRST STAGE OF LABOUR

3.1 Assessing the Start of Labour

3.2 Position and Movement during the First Stage of Labour

3.3 Vaginal Examination

3.4 Monitoring the Progress of Labour

3.5 Prevention of Prolonged Labour

(introduction...)

3.5.1 Early amniotomy

3.5.2 Intravenous infusion of oxytocin

3.5.3 Intramuscular oxytocin administration

4. CARE DURING THE SECOND STAGE OF LABOUR

4.1 Physiological Background

4.2 The Onset of the Second Stage

4.3 The Onset of Pushing during the Second Stage

4.4 The Procedure of Pushing during the Second Stage

4.5 Duration of the Second Stage

4.6 Maternal Position during the Second Stage

4.7 Care of the Perineum

(introduction...)

4.7.1 “Guarding the perineum” during delivery

4.7.2 Perineal tear and episiotomy

5. CARE DURING THE THIRD STAGE OF LABOUR

5.1 Background

5.2 Prophylactic use of Oxytocics

5.3 Controlled Cord Traction

5.4 Active Versus Expectant Management of the Third Stage

5.5 Timing of Cord Clamping

5.6 Immediate Care of the Newborn

5.7 Care of the Mother Immediately after Delivery of the Placenta

6. CLASSIFICATION OF PRACTICES IN NORMAL BIRTH

(introduction...)

6.1 Practices which are Demonstrably Useful and Should be Encouraged

6.2 Practices which are Clearly Harmful or Ineffective and Should be Eliminated

6.3 Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue

6.4 Practices which are Frequently Used Inappropriately

7. REFERENCES

8. LIST OF PARTICIPANTS

SAFE MOTHERHOOD RESOURCE LIST

BACK COVER

3.4 Monitoring the Progress of Labour

The assessment of the progress of labour is made by observation of the woman; her appearance, behaviour, contractions, and the descent of the presenting part. The most accurate measure is dilatation of the cervix. Deviation from an arbitrarily defined normal rate of dilatation should be an indication for review of the labour management plans. In the partograph method of WHO (WHO 1993) the alert line is passed if the dilatation is slower than 1 cm per hour; if the woman is in a health centre this is reason to refer her to a hospital. The action line is passed if delay in progress continues for four more hours. Then a critical assessment of the cause of delay should be made, and a decision taken about the appropriate management. Although these strict rules are not followed in all countries, they form valuable guidelines, especially in those situations where distances to a referral centre are great, and birth attendants are isolated. Research about the effect of the use of the partograph showed that over a fifth of the graphs of primigravidae crossed the alert line, and 10-11% crossed the action line (Philpott and Castle 1972, WHO 1994b). In Latin America a different partograph is in use, differentiating between nulliparous and multiparous women, intact and ruptured membranes, and upright or lying position (Schwarcz et al 1987-1995).

The relationship between prolonged labour and adverse maternal and fetal outcome is the reason why it is so important to monitor the progress of labour accurately. The extent to which that relationship is causal is by no means certain. Slow progress should be a reason for evaluation rather than for intervention. Cephalopelvic disproportion must be considered when progress is slow. Intrapartum X-ray pelvimetry has not proven to be useful. The available trials of X-ray pelvimetry show an increase of interventions like caesarean section, but no benefits in terms of reduced neonatal morbidity (Parsons and Spellacy 1985). X-ray pelvimetry during pregnancy and labour increases the incidence of leukaemia in infancy, and should be abolished (Stewart et al 1956, MacMahon 1962). In experienced hands manual pelvimetry may be useful. If the membranes are still intact during labour slow progress is usually not caused by disproportion. Expectant management would then be an option (Albers et al 1996). As no solid research evidence is available about expectant management versus active management in case of slow progress without signs of disproportion, no definite conclusions can be drawn. When the membranes are ruptured slow progress is more likely to be the consequence of mechanical problems. The management in cases of abnormal labour is beyond the scope of this report.