Current Management Of Labour

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 10/22/08

Prof AAE Orhue

1

CONTD 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 10/22/08 Prof AAE Orhue 2 parturient in

CONTD 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 10/22/08

Prof AAE Orhue

3

CONTD 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. 10/22/08

Prof AAE Orhue

4

CONTD 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. 10/22/08

Prof AAE Orhue

5

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 10/22/08

Prof AAE Orhue

6

CONTD -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. 10/22/08

Prof AAE Orhue

7

CONTD -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. 10/22/08

Prof AAE Orhue

8

CONTD -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. 10/22/08

Prof AAE Orhue

9

CONTD -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 10/22/08

Prof AAE Orhue

10

3.

CONTD 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. 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 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. The protocol that brought this monumental achievement of extremely low prolonged labour rate and C.S rate was

4.

5.

10/22/08

Prof AAE Orhue

11

CONTD 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 10/22/08

Prof AAE Orhue

12

2.

3. 4.

5.

CONT Cervical dilatation rate is the most objective basis for assessing progress in labour and not the subjective assessment of contraction quality or head descent. The normal labour progress is a cervical dilatation rate of 1cm per hour from active labour until delivery. 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. 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. 10/22/08

Prof AAE Orhue

13

2.

3.

4.

5.

CONTD 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 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. 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 The primigravida uterus is immuned to uterine rupture with oxytocin augmentation except with a previous scar or manipulations in labour. Prof AAE Orhue 10/22/08 14

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. 10/22/08

Prof AAE Orhue

15

2.

3.

4.

5.

CONTD 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. 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. 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. 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 10/22/08

Prof AAE Orhue

16

3.

4.

5. 6.

CONTD 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. 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. 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. The labour pain relief was regularly with narcotic analgesics but epidural was allowed for those who requested. 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 10/22/08

Prof AAE Orhue

17

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. 10/22/08

Prof AAE Orhue

18

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. 10/22/08

Prof AAE Orhue

19

2. 3. 4. 5. 6. 7.

CONTD The need for Senior obstetric staff to confirm the active labour before starting the A.M.L. protocol. The hourly VE was feared would introduce infection in labour. The high augmentation based on not dilating at the cervical dilatation rate of 1cm per hour even from early labour. The oxytocin augmentation regimen which was only for 4 hour duration or one litre of fluid only. The need for a nurse for every parturient through out labour. The overall cost consequent on high consumables from the frequent V.E. and staff required.

10/22/08

Prof AAE Orhue

20

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 10/22/08

Prof AAE Orhue

21

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. - 10/22/08 The details of the Philpot’s protocol is as follow: Prof AAE Orhue 22

2.

3.

4.

CONTD 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. 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. 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 10/22/08

Prof AAE Orhue

23

3.

4.

CONTD 4 hourly interval till delivery. 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. 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. 10/22/08

Prof AAE Orhue

24

2.

3.

4.

CONTD 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. 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. 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. 10/22/08

Prof AAE Orhue

25

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. 10/22/08

Prof AAE Orhue

26

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 10/22/08

Prof AAE Orhue

27

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. 10/22/08

Prof AAE Orhue

28

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. 10/22/08

Prof AAE Orhue

29

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 10/22/08

Prof AAE Orhue

30

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 10/22/08

Prof AAE Orhue

32

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) 10/22/08

Prof AAE Orhue

33

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. 10/22/08

Prof AAE Orhue

34

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 10/22/08

Prof AAE Orhue

35

3.

4. 5.

CONTD of latent phase into normal and prolonged latent phase tended to suggest that prolonged latent phase was an extreme anomaly. 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. 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. 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. 10/22/08

Prof AAE Orhue

36

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 10/22/08

Prof AAE Orhue

37

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. 10/22/08

Prof AAE Orhue

38

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 10/22/08

Prof AAE Orhue

39

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 10/22/08

Prof AAE Orhue

40

CONTD 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. 10/22/08

Prof AAE Orhue

41

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 10/22/08

Prof AAE Orhue

42

CONTD 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. 10/22/08

Prof AAE Orhue

43

•

•

•

•

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 10/22/08

Prof AAE Orhue

44

3.

4. 5.

6. 7.

CONTD assess and define the cause of the delay at the next VE 2 hour apart maximum 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. Oxytocin augmentation is performed only for a duration of 8 hours with VE assessment at 2 hourly intervals. 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. All decision for C/S is taken at the level of the SR in consultation with the consultant on call. A nurse is assigned throughout to any woman on oxytocin augmentation. 10/22/08

Prof AAE Orhue

45

2.

CONTD 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. 10/22/08

Prof AAE Orhue

46

CONTD 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. 10/22/08

Prof AAE Orhue

47

CONTD 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. 10/22/08

Prof AAE Orhue

48