**5.1 Normal delivery**

Normal childbirth is a retrospective diagnosis that refers to spontaneous delivery starting after a full-term pregnancy, with absence of risk factors and/or complications. The goal of all deliveries is healthy mother, healthy baby and a positive childbirth experience.

In the first stage of labor, uterine contractions increase in frequency and strength. Since Freedman's work in the 1950s, it is considered that normal cervical dilatation during the first stage of labor is 1 cm/hour which gives a mean duration of first stage of 4.5 hours. An opening stage with a 2-3 hours delay is considered as extended or dystosic (Friedman 1955).

#### **5.2 Labor dystocia**

Labor dystocia is a common worldwide obstetrical problem, and is one of the main indications for operative intervention during parturition. Labor dystocia is clinically defined as slow/arrest of progress during labor, i.e. cervical dilatation and descent of the presenting part. It is estimated that labor dystocia occurs in about 20% of all deliveries worldwide. However, it is difficult to find a precise definition of the diagnosis of dystocia. The usual method to identifying labor dystocia is to use a partogram with an `alert line´ representing cervical dilation of 1 cm per hour and an `action line´ drawn 2-4 hours to the right of the `alert line´ (Philpot 1972). The clinical method of identifying dystocia is when the graphically plotted rate of progress crosses the action line or if no progress is made over the previous 2 hours (Lavender 2008).

Labor dystocia is associated with increased risks, such as labor abnormalities, increased risk of instrumental/operative intervention, depressed Apgar score at 5´minutes and extended need for newborn care. Dysfunctional labor is also associated with a higher frequency of postpartum infections, higher estimated maternal blood loss and lengthened maternal and newborn hospital stay.

#### **5.3 Partogram**

According to World Health Organisation (WHO) every delivery in the world should have a partogram presented during labor (Kwast et al 1994). The partogram detects maternal and fetal complications and the progress of labor. The background of the partogram, the cervicoplot, was constructed by Friedman during the 1950´s. Friedman analyzed the average

Lactate Level in Amniotic Fluid, a New Diagnostic Tool 229

In early 1990's the WHO partogram was evaluated in a review and it was found that the use of partogram reduces the proportion of deliveries with dystocia, the number of emergency caesarean section and the frequency of stillbirths. Against this background, WHO has

Nowadays the partogram has been questioned, particularly in terms of design and efficiency. In a Cochrane review the use of partogram was evaluated and a compare with no use of partogram. An evaluation of the partogram with different placement of the ACL was also made. The results were inconclusive and showed that the use of partogram neither decreased the caesarean rates nor gave higher Apgar score at 5 minutes. Four hours displaced ACL lowered the proportion of deliveries stimulated with oxytocin. ACL with 2-hour shift seemed to provide better maternal delivery experience, but no other benefits. In summary, design and use of the partogram is questioned and there is a need for other complementary methods to monitor delivery and to identify slow progress of

In the late 1960s 0´Driscoll and co-workers at National Maternity Hospital in Dublin, Ireland, carried out some pioneering work on normal/dysfunctional labor (O'Driscoll et al. 1969; O'Driscoll et al. 1973). They approached the management of labor in nulliparas' women, which is nowadays referred to as `active management of labour´. The method includes 1) strict criteria for the diagnosis of labor, 2) early rupture of the membranes, 3) prompt intervention with oxytocin and 4) a commitment to never leave the labouring women unattended during the period of labor. This constitutes `active management of

Trials have been conducted with some of the strict diagnostic criteria such as early amniotomy, early oxytocin stimulation in the event of abnormal progress of labor (inefficient myometrial contractions), and a commitment to never leave a labouring women unattended during the period of labor. Most of these studies have, however, been based on normal labor and not on dystosic ones. Some criticism has been made of the aggressive approach, and a combination of these interventions. There have only been a few randomised studies with `the total package of management of labor´ (Akoury et al 1988; Turner et al. 1988; Boylan et al 1991; Lopez-Zeno et al 1992; Frigoletto et al 1995), and only one of these showed significantly reduction in odds ratio (OR) for caesarean birth associated with active management (Lopez-Zeno et al 1992). In contrast continuous professional support in labor

The essential function of AF is to cushion the fetus (Williams et al. 1980). The fluid gives the fetus space to grow, and allows it to undergo a `physical´ development. The AF function is also to protect the fetus from trauma and to maintain temperature. It also has a minimal

has been shown to reduce the rate of operative interventions.

recommended an universal use of the partogram since 1994 (Kwast et al 1994).

labor.

labor´.

**6. Amniotic fluid** 

nutritive function.

**6.1 Amniotic fluid production** 

**5.4 Active management of labor** 

of cervical dilatation speed during active phase of the 10% women with the slowest labor progress, and estimated a normal progress to be 1 cm /hour. Original curves of the cervical dilation were sigmoid with a clear transition between first and second stage of labor. The partogram has been an important tool in obstetric care since the 1950's.

Some years after Friedman's published work, Philpot and Castle constructed the first partogram. The sigmoid curve was now translated to a straight line with an expected progress of labor with 1 cm/h. This line, which is plotted in most partogram of today, is called the alert line (AL) and corresponds to the expected labor progress. The midwife or the obstetrician in charge should pay attention if labor progress deviate from the expected progress. In the development of the partogram, AL was supplemented with Action Line (ACL). When progress of labor passed ACL a dysfunctional labor was diagnosed. If labor progress crossed the ACL, intervention is recommended primarily with amniotomy and thereafter with oxytocin stimulation. The location of the ACL differs between countries and is usually placed 2-4 hours from the AL. In Sweden the ACL with the 2-hours shift is used. 

Fig. 2. The WHO Partogram

of cervical dilatation speed during active phase of the 10% women with the slowest labor progress, and estimated a normal progress to be 1 cm /hour. Original curves of the cervical dilation were sigmoid with a clear transition between first and second stage of labor. The

Some years after Friedman's published work, Philpot and Castle constructed the first partogram. The sigmoid curve was now translated to a straight line with an expected progress of labor with 1 cm/h. This line, which is plotted in most partogram of today, is called the alert line (AL) and corresponds to the expected labor progress. The midwife or the obstetrician in charge should pay attention if labor progress deviate from the expected progress. In the development of the partogram, AL was supplemented with Action Line (ACL). When progress of labor passed ACL a dysfunctional labor was diagnosed. If labor progress crossed the ACL, intervention is recommended primarily with amniotomy and thereafter with oxytocin stimulation. The location of the ACL differs between countries and is usually placed 2-4 hours from the AL. In Sweden the ACL with the 2-hours shift is used.

partogram has been an important tool in obstetric care since the 1950's.

Fig. 2. The WHO Partogram

In early 1990's the WHO partogram was evaluated in a review and it was found that the use of partogram reduces the proportion of deliveries with dystocia, the number of emergency caesarean section and the frequency of stillbirths. Against this background, WHO has recommended an universal use of the partogram since 1994 (Kwast et al 1994).

Nowadays the partogram has been questioned, particularly in terms of design and efficiency. In a Cochrane review the use of partogram was evaluated and a compare with no use of partogram. An evaluation of the partogram with different placement of the ACL was also made. The results were inconclusive and showed that the use of partogram neither decreased the caesarean rates nor gave higher Apgar score at 5 minutes. Four hours displaced ACL lowered the proportion of deliveries stimulated with oxytocin. ACL with 2-hour shift seemed to provide better maternal delivery experience, but no other benefits. In summary, design and use of the partogram is questioned and there is a need for other complementary methods to monitor delivery and to identify slow progress of labor.

### **5.4 Active management of labor**

In the late 1960s 0´Driscoll and co-workers at National Maternity Hospital in Dublin, Ireland, carried out some pioneering work on normal/dysfunctional labor (O'Driscoll et al. 1969; O'Driscoll et al. 1973). They approached the management of labor in nulliparas' women, which is nowadays referred to as `active management of labour´. The method includes 1) strict criteria for the diagnosis of labor, 2) early rupture of the membranes, 3) prompt intervention with oxytocin and 4) a commitment to never leave the labouring women unattended during the period of labor. This constitutes `active management of labor´.

Trials have been conducted with some of the strict diagnostic criteria such as early amniotomy, early oxytocin stimulation in the event of abnormal progress of labor (inefficient myometrial contractions), and a commitment to never leave a labouring women unattended during the period of labor. Most of these studies have, however, been based on normal labor and not on dystosic ones. Some criticism has been made of the aggressive approach, and a combination of these interventions. There have only been a few randomised studies with `the total package of management of labor´ (Akoury et al 1988; Turner et al. 1988; Boylan et al 1991; Lopez-Zeno et al 1992; Frigoletto et al 1995), and only one of these showed significantly reduction in odds ratio (OR) for caesarean birth associated with active management (Lopez-Zeno et al 1992). In contrast continuous professional support in labor has been shown to reduce the rate of operative interventions.
