Oxford Handbook of Midwifery (58 page)

Amniotic

fluid Placenta

Cervix
_Uterus

(a) Left occipito-anterior (b) Right occipito-lateral (c) Right occipito-posterior

1. Right occipito-anterior (e) Left occipito-lateral (f) Left occipito-posterior
   

   Fig. 11.1
   Cephalic presentations prior to labour.
   

   Reproduced from
   Acupuncture in Pregnancy and Childbirth
   . Zita West (2001) Copyright © Elsevier Limited 2001, reprinted by permission of the publisher.
   

   CHAPTER 11
   Normal labour: first stage
   

   232‌‌
   

   Vaginal examination
   

   In normal labour, vaginal examination is performed at the discretion of the midwife, dependent on the individual needs of the woman, consent, and her progress through labour. Sensitivity should be employed at all times, as many women find vaginal examinations uncomfortable and traumatic. Where possible, examinations should be kept to a minimum (only when clinically indicated) and ideally should be performed by the same person.
   

   Indications
   

   Vaginal examination may be undertaken to:
   

   • Confirm the establishment of labour
     
   • Provide a baseline for subsequent progress
     
   • Assess progress in labour and detect abnormal indices
     
   • Assess the presenting part/position if in doubt (Fig. 11.2)
     

Symphysis pubis

Occipito-posterior position

Right

Left

Right

Left

Sacrum

right occipito-posterior

Sacrum

left occipito-posterior

Symphysis pubis

Occipito-anterior position

Right

Left

Right

Left

Sacrum

left occipito-anterior

Sacrum

right occipito-anterior

Fig. 11.2
Occipito-anterior and occipito-posterior positions.

Reproduced from
Acupuncture in Pregnancy and Childbirth
. Zita West (2001) Copyright © Elsevier Limited 2001, reprinted by permission of the publisher.

VAGINAL EXAMINATION

233

Method

Discussion with the woman is essential before examination, to explain the procedure, reassure, and gain consent.

CHAPTER 11
Normal labour: first stage

234‌‌

The partogram

The partogram is a graphical overview of the physical elements and events that take place in an individual woman’s labour. This has proved to be an invaluable, at a glance, visual aid and reference for midwives during their care of women in labour. It is especially useful when handing over the woman’s care to a colleague, as it provides an instant summary of the woman’s progress to date. The partogram is usually commenced when the woman is in established labour. Details recorded on the partogram are:

• Hospital number, name of woman, age, parity, date of birth, and expected date of confinement
  
• The fetal heart rate, plotted at regular intervals (see b Electronic fetal monitoring, p. 238, for NICE guidelines on frequency of auscultation of the fetal heart rate)
  
• Observation of the liquor, and what time the membranes ruptured
  
• Cervical dilatation and descent of the presenting part, plotted diagrammatically
  
• Oxytocic agents if used during labour
  
• Uterine activity: the length and strength of the contractions per 10min
  
• Drugs, inhalational analgesia, and non-pharmacological interventions used
  
• Urinalysis
  
• Blood pressure and pulse.
  

  Legally the partogram provides a complete and comprehensive record of care and should include the following information:
  

• Time of birth, gender of baby, and weight
  
• Any abnormalities noted at birth
  
• Mode of birth
  
• Apgar score and any resuscitation/intervention/drugs given to the baby
  
• Length of the first, second, and third stages of labour
  
• Blood loss
  
• Perineal repair or status of perineum
  
• Whether meconium or urine passed during or post birth
  
• Feeding intention and summary of feeding/skin to skin contact.
  

  Originally, it was noted that use of the partogram would easily recognize
  

  cases of prolonged labour, so that appropriate action/intervention could be taken. However, this also tends to create a structured and rigid approach
  

  to care, which some midwives find restrictive, while not addressing the woman’s individual needs.
  

• Most research on the first stage of labour is based on a medical model of care, where interventions are commonplace, and may not reflect normal labour and physiology.
  
• The length of labour may well be much longer than originally anticipated, particularly in primigravid women.
  

  THE PARTOGRAM
  

  235