CH02

SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS
CHAPTER 2
MANAGEMENT OF LABOR and
OBSTRUCTED LABOR
2.1 MANAGEMENT OF LABOR
Learning Objective!
Define and diagnose labor
Recognize normal and abnormal progress of labor
Review the etiology of labor
Apply appropriate prevention and or management strategies for abnormal progress of labor
A 25-year-old G1 presented to the maternity unit four hours ago with contractions every 5 minutes. Her vaginal
exam at the time revealed a cervix that is 2 cm dilated 1.5 cm in length, with vertex at station -. !he is now
re"uesting analgesia and reexamination finds no significant change in the cervix and the station is -2. #hat would
$e an appropriate plan of management at this time%
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
#hat would $e an inappropriate plan of management at this time%
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
'f the cervix was 5 cm dilated and fully effaced, would this change the approach to the situation%
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&&
Over the past few decades, there has been a dramatic increase in the number of cesarean sections being performed
throughout the world. Cesarean section is associated with increased maternal morbidity and mortality, increased
neonatal morbidity, and increased health care costs. Dystocia accounts for the majority of cesarean sections. Clearly,
appropriate and optimal management of labor and dystocia, if it occurs, could potentially lead to a significant
reduction in the cesarean section rate.
nduction of labor is associated with an increase in the incidence of dystocia in latent phase. !his leads to an
increase in obstetrical interventions especially in the nulliparous woman with an unfavourable cervi".
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 21
2.1.1 Definitions
n order to assess progress in labor, we need to be confident in our definition of active labor and abnormal progress.
Labor
s
Regular, $re%uent &terine Contractions
'
Cervical Change
(dilatation and effacement)
First stage:
*atent +hase, is the presence of uterine activity resulting in progressive effacement and dilatation of the cervi"
preceding the active phase. *atent phase is complete when a primiparous woman reaches -./ cm dilatation and
cervical length of 0.0.1 cm and a multiparous woman reaches /.1 cm and cervical length 0.1.2.0 cm. !he onset
of the latent phase is often difficult to define. t can be difficult to separate from false labor and the true length
of this stage is often assessed retrospectively.
Active phase re%uires the presence of regular painful contractions leading to more rapid cervical dilatation after
-./ cm dilatation in a primiparous woman, or /.1 cm dilatation in a multiparous woman.
Second Stage: (divided into two components)
Passive: 3arly descent occurs during the time from full dilatation until an urge to push is felt (about station'4).
Active: !he second component is usually associated with maternal e"pulsive effort and is the time from the
onset of the urge to push until delivery.
nade%uate progress of labor is associated with increases in maternal stress, maternal infection, postpartum
hemorrhage and the need for neonatal resuscitation. !ools such as partograms are essential to demonstrate and
highlight inade%uate progress in labor.
n evaluating the cause of dystocia, we can refer to the three +s, +owers, +assenger, and +assage. !he powers
are the most li5ely to be responsible for dystocia, and are the most readily evaluated and influenced. neffective
contractions, usually early in labor, are responsible for appro"imately 46- of dystocias in nulliparous women.
2.1.2 Use of the Partograph in Labor
Why the Partograph?
!he delivery of a healthy baby and maintenance of a safe delivery for the mother are two goals of all
maternity health care givers. A simple instrument called a partograph can aid this basic human right of safe
passage. !he partograph has been shown to reduce prolonged labor, the need for augmentation, emergency
caesarian section and intrapartum stillbirth rates. t should be used in all labor wards and centers for
maternity care. !he following recommendations are adapted from the 7orld 8ealth Organization
recommendations on the use of the partograph, (see Appendi" 2A and 29)
When sho!d one se the partograph?
A partograph should be started on women in labor who have :O complications that re%uire immediate
action. ;tart O:*< when the woman is in labor=this means two contractions in ten minutes (lasting 40
seconds or more) in the latent phase (cervical dilatation of 0.4 cm). n the active phase (cervical dilatation
of -.20 cm), the contractions should be one per ten minutes (lasting 40 seconds or more).
What does the partograph invo!ve?
!he partograph demands the assessment of several observations=the first relate to progress of labor
(cervical dilatation, descent of the fetal head and uterine contractions). !he second set of observations
focuses on the fetus, fetal heart rate, membranes and li%uor and moulding of the fetal head.
!he D*A!A!O: is plotted with an "#$. After the first vaginal e"amination, repeat e"ams are every four
hours (with a more fre%uent assessment if the woman is multiparous or in advanced labor).
Descent is assessed abdominally in fifths above the pelvic brim. An abdominal e"amination should be
done before the pelvic assessment. Contractions are observed for fre%uency and duration. !he number of
contractions in ten minutes is recorded with three ways of shading on the partograph, a) less than 40
seconds b) 40./0 seconds and c) greater than /0 seconds.
>embranes are denoted as,
?intact C?ruptured and clear >?meconium A?ruptured but absent li%uor
%hings to re&e&ber:
;atisfactory progress means the plot of cervical dilatation will remain O: or *3$! of the A*3R! *:3.
!he latent phase should not last beyond eight hours. f a mother is admitted in latent phase, start plotting at
time zero hours. Once in the active phase, plotting of dilatation is transferred to the A*3R! line. f a
patient is admitted already in the active phase, dilatation is plotted immediately on the A*3R! line.
*isten to fetal heart rate after pea5 of contractions with a woman on her left side. !he fetal heart rate should
be 240.2@0 beats per minute. Record the fetal heart rate every -0 minutes during the first stage of labor.
ncreasing moulding with a high fetal head is a sign of cephalopelvic disproportion.
Actions on the Partogra&:
%he A!ert Line:
A laboring mother should be referred from a health center to a hospital when the cervical dilatation moves
to the RA8! of the A*3R! line. Amniotomy may be performed if the membranes are still intact=she
may be observed for a short time prior to transfer. n hospital, movement to the RA8! of the A*3R! line
should signal the need for an amniotomy and close observation.
%he Action Line:
f the patientBs partograph crosses the AC!O: line in a central hospital, active intervention is re%uired.
nitially this would include, the start of an intravenous line, bladder catheterization, analgesia and
augmentation using o"ytocin. !hese measures would be carried out as long as there was no evidence of
fetal distress or obstructed labour.
A vaginal e"amination should be carried out in three hours, then in two more hours (and every two hours
thereafter). !he dilatation rate should be 2cm6hour minimum. C83CC the $3!A* 83AR! rate every half
hour at minimum when o"ytocin is being infused. f these measures are not successful, a cesarian section
would be carried out.
Pro!onged Latent Phase:
n the case of a woman with a prolonged latent phase (DE hours), a full assessment must be carried out. s
she truly in labor=if not, abandon the partograph. One may consider an amniotomy plus o"ytocin infusion
if there is no evidence of fetal distress and the contraction pattern is not satisfactory. A final option is
cesarian section=especially if evidence of obstruction or need for imminent delivery.
Antibiotics should be given if the membranes have been ruptured for more than 24 hours.
$etal distress should be managed aggressively, if the woman is in a health centre, transfer to hospital (for
operative delivery) immediately. f the woman is in hospital, stop o"ytocin, turn on left side, e"amine for
cord prolapse and hydrate. f the fetal distress does not resolve, an immediate cesarian section is needed.
2.1.' (tio!ogy of Dystocia
P)W(*S ineffective contractions
maternal e"pulsive efforts (second stage)
fetal position
PASS(+,(* fetal attitude
fetal size
fetal abnormalities e.g. hydrocephalus
PASSA,( bony pelvis abnormality
soft tissue causes, tumours
full bladder6full rectum
vaginal septum
!he diagnosis of true or absolute cephalopelvic disproportion (C+D) should be limited to the uncommon instances
of real disproportion i.e. inability of the well fle"ed head (sub.occipito bregmatic presentation) to pass through the
bony pelvis. Other presentations may lead to relative cephalopelvic disproportion.
f the woman is ma5ing satisfactory progress in labor then the interaction of the three +Bs must be ade%uate. !hese
three variables act together and should generally not be assessed in isolation.
f progress is inade%uate, attention should be directed to,
2. Ade-ate Po.ers:
Contractions that areF
2) Regular
4) +rogressive, which lead to cervical dilatation
-) $re%uent ( 4.- minutes)
4. %he Passenger should be assessed for size and malposition. nade%uate powers in active labor may be
responsible for malposition. A normal sized infant may present an e"cessively large diameter to the pelvis
because the head is not fle"ed.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2!
-. %he Passage: Clinical e"amination of the passage may reveal prominent spines or sacrum, a narrow pubic arch
or a space.occupying mass in the pelvis. A trial of labor is the only real assessment of the pelvic ade%uacy.
2.1./ Prevention and 0anage&ent of Dystocia
11 Prevention
Accrate Diagnosis of Labor
;ome cesarean sections performed for dystocia in nulliparous patients are done in the latent phase of labor.
t is li5ely that at least a portion of these women were not in true labor at the time of labour management
interventions or at the time of cesarean section. Appropriate management, of suspected early labor, could
result in a decrease in the cesarean section rate.
0anage&ent of Pro!onged Latent Phase
Different definitions of prolonged latent phase e"ist including greater than 40 hours in a primip, or a time
limit of si" hours from admission to health center to - cm dilatation. f women are not admitted until they
are in active labor, this latter definition becomes irrelevant. Regardless, it is important to separate this
entity from false labor.
>anagement is controversial due to the limited number of published studies.
!he patient should preferably not be admitted to the labor and delivery area.
Observation, rest and analgesia are favoured over a more active approach of amniotomy and o"ytocin
induction.
Labor Preparation
$or nulliparous women who have attended prenatal education, there may be more rapid progress in labor.
;ome studies have shown a benefit and others show no difference, but all studies show that women who
were prepared for labor had a more positive e"perience. !rials also show that prenatal education decreases
the amount of analgesia used during labor.
2irth 3o&panion
!here is now strong evidence that the presence of a supportive companion results in faster progress and less
dystocia. !his companion should have e"perience with labouring women, but is not necessarily trained in a
health discipline.
A&b!ation
t is important to recognize the womenBs choice of labor position. Ambulation and upright posture reduces
the amount of pain perceived by women in labor. !he use of a birth stool often helps if the woman does not
want to wal5. &pright posture in labor may be useful in reducing bac5pain and the need for epidural
anesthesia. ;tatic supine position may result in aorto.caval compression, hypotension and non.reassuring
fetal monitoring.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2"
%A2L( 4 %5( P)S6%67( (FF(3%S )F A02ULA%6)+ 6+ LA2)*
Ana!gesia
;ome patients in labor reach the limit of their pain tolerance. $urthermore, patients e"periencing e"cessive
pain or an"iety have high endogenous catecholamines. !his produces a direct inhibitory effect on uterine
contractility and establishes a vicious circle of poor uterine progress leading to increased an"iety, leading to
increased catecholamines, leading to further impairment of progress. !he relief of pain by effective
analgesia may allow release of the uterus from the constraints of the endogenous catecholamines and
enhance progress in labor. 8igh endogenous catecholamine levels may also adversely affect uterine blood
flow and therefore fetal o"ygenation.
A&nioto&y 8A*091
Routine early use of amniotomy after - cm dilatation shortens the average length of labor, but does not in
itself reduce the incidence of dystocia or cesarean section. 3arly amniotomy at less than - cm dilatation
may increase the incidence of dystocia.
A()* Artificial (upture of the )em$ranes
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2#

Severe bac: pain 8n;<21
Any ana!gesia 8n;12/=1
(pidra! 8n;/>11
Ag&entation 8n;='=1
)perative vag de!ivery 8n;1=?=1
3esarean section 8n;1=?=1
)dds *atio 8@<A 3onfidence 6nterva!1
)tco&e 8sbBects1
0.2 2 20
Feta! SiCe
$etal size does not significantly affect the progress of labor in first and second stage.
21 0anage&ent
f an arrest disorder is diagnosed, management is as follows,
Arrest without C+D . amniotomy
. consider o"ytocin augmentation if contractions are inade%uate
Arrest with true C+D . cesarean section
)Dytocin
n the event of unsatisfactory progress (G0.1cm6hr " / hours or arrest of descent for over 2 hour) in the
active phase of labor, o"ytocin is indicated. 9efore the use of o"ytocin, consideration should be given to
the appropriate use of analgesia, hydration, rest and amniotomy.
O"ytocin should be used to achieve ade%uate contractions before operative delivery is considered.
Concern is sometimes raised about the use of o"ytocin. !he principal complications that cause
apprehension are fetal compromise and uterine rupture due to uterine hyperstimulation. Hudicious use of
o"ytocin should not result in complications.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2$
.
%A2L( 4 %5( (FF(3% )F A0+6)%)0E
3erviD A*0 +o A*0 *.*.
%i&e to F!! Di!ation A!! 2FF /1'
8&intes1 G'c& //2 <1<
H'c& 2>? '=<
Dystocia A!! '/A /<A ?.=
G'c& '>A '?A 1.2
H'c& ''A /=A ?.F
3aesarean 12A 11A
Fraser et a!I +(J0 1@@'
$etal hypo"ia may occur accompanying spontaneous contractions. Hudicious use of o"ytocin produces
contractions with intrauterine pressures e%uivalent to spontaneous labor. f the fetus develops signs of fetal
hypo"ia with these contractions, this is due to pre.e"isting uteroplacental insufficiency and not to the
o"ytocin. nappropriate use of o"ytocin may produce hyperstimulation and decrease transplacental o"ygen
transport to the fetus.
n the primigravida rupture of the uterus in association with o"ytocin is almost un5nown. 8owever care
must be ta5en in the multipara and those with previous uterine surgery.
All labor and delivery units must be prepared to manage uterine hyperstimulation whether it is associated
with o"ytocin use or not. >anagement of uterine hyperstimulation is outlined in the section on induction
of labor.
!he following are possible complications, their mechanism of occurrence and preventative management,
with the use of o"ytocin.
Adverse (ffects of )Dytocin and %heir Prevention
Adverse 3ffects >echanism +revention
$etal compromise 8yperstimulation Correct dose
&terine rupture 8yperstimulation Correct dose
3ach womanBs uterus varies in its sensitivity to o"ytocin. 3ven in the same uterus, the sensitivity may
change during the course of labor. !he dose must be sufficient to achieve ade%uate contractions. +rotocols
or guidelines for the administration of o"ytocin vary but suggest starting with a low dose and small
increments at intervals of -0 minutes. ;tarting incremental dosages for augmentation may be less than
those for induction.
Ag&entation of Labor
nitial dose of o"ytocin 2.4m&6min
ncrease interval 3very -0 minutes
Dosage increment 2.4m&
&sual dose for good labor 4.24m&6min
t is important to allow ade%uate time for o"ytocin to wor5. !his is especially true if it is started when the cervi" is
less than 1 cm dilated. Do not e"pect to see immediate progress.
$or the conversion to the e%uivalent to drops per minute (40 drops?2ml),
)Dytocin +or&a! Sa!ine Drops
20 unites 100 ml 2mu ? 2 drop
1 unites 2 lt 2mu ? / drops
20 unites in 2 lt 2mu ? 4 drops
Active 0anage&ent of Labor
Active management of labor encompasses the following principles,
Rigorous diagnosis of labor
Close surveillance of progress of labor by partogram
Continuous support in labor
3arly intervention to correct inade%uate progress of labor,
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2%
AR>
O"ytocin
!his has been shown to reduce the incidence of dystocia and cesarean sections.
0anage&ent of the Pro!onged Second Stage
;etting an arbitrary time limit for the second stage in the absence of suspected fetal compromise, is not well
founded. 7omen should not be encouraged to push until the head has descended to the pelvic floor and
they feel the urge to do so. f no urge to push occurs after one hour of second stage, reassess the
contractions and consider the use of o"ytocin if contractions are inade%uate. A lac5 of descent in the
absence of moulding or caput is li5ely due to inade%uate contractions.
2.1.< S&&ary
Prevention of Dystocia
Avoid unnecessary induction
Admit only women in active labor
3ncourage ambulation and upright posture
3ncourage the use of prenatal education
Continuous support of laboring women
&se appropriate analgesia
0anage&ent of Dystocia
Appropriate assessment of ade%uate progress in labor
Appropriate intervention when necessary
Amniotomy
Analgesia
Rest
Ambulation
Augmentation
Cesarean sections
*eferences,
2. Cwast 9 et al., 7orld 8ealth Organization partograph in management of labour. *ancet, 2II/, -/-,2-II.2/0/.
4. 78O. J+reventing +rolonged *abour, A +ractical Auide.K !he +artograph. Aeneva, >aternal 8ealth and ;afe
>otherhood +rogramme, Division of $amily 8ealth, 2II/.
-. ;OAC JD<;!OCAK. ;OAC +olicy ;tatement :o. /0, October 2II1
/. Ceirse >H:C, Chalmers . n, Chalmers, 3n5in, Ceirse (3ds). 3ffective Care in +regnancy and Childbirth.
O"ford &niversity +ress, O"ford, 3ngland, 2IEI.
1. $riedman 3A. *abour, Clinical evaluation and management. ;econd edition (:ew <or5). Appleton Century
Crofs. 2IL@. ;tudd H77 (3d). !he >anagement of *abour. O"ford, 9lac5well ;cientific +ublications, 2IE1.
@. OBDriscoll C, $oley >, >acDonald D. Active management of labor as an alternative to caesarean section for
dystocia. Obstet Aynecol 2IE/M @-, /E1.I0
L. A5oury 8A, 9rodieA, Caddic5 R, >c*aughlin ND, +ugh +A. Active >anagement of *abor and Operative
Delivery in :ulliparous 7omen. A> H Obstet Aynecol 2IEEM411
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # 2&
2.2 OBSTRUCTED LABOR
2.2.1 Definitions
J$ailure of descent of the fetus in the birth canal for mechanical reasons in spite of good uterine contractionsK.
(+hilpott, 2IE4)
2
6ncidence
2 . -O
4
*is:s Associated .ith +eg!ected )bstrcted Labor
Feta!:
Asphy"ia
;epsis
Death
0aterna!:
;epsis
&terine rupture
8emorrhage
$istula (Nesico.vaginal, recto.vaginal)
Death

2.2.2 (tio!ogy of )bstrcted Labor
Feta! . +elvic Disproportion,
>alpresentations
. $ace
. 9row
. ;houlder6arm presentation . !ransverse lie
. 9reech
. Compound presentation
>alposition. +ersistent occipito posterior
. +ersistent occipito transverse
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # '
Learning Objective!
Define and diagnose obstructed labor
Review etiology and clinical presentation
Discuss treatment of obstructed labor
>alformations
. 8ydrocephalus
. Abdominal tumors (eg. 7ilms !umor)
. Cystic 8ygroma
. Conjoined twins
0aterna!
;mall pelvis
. Childhood malnutrition
. Contracted or deformed bony pelvis
;oft tissue tumors of the pelvis
. &terine fibroids
. Ovarian tumors
. Rectal tumors
3!inica! Featres of )bstrcted Labor
n most cases, prolonged labor preceeds obstruction. 8owever, in the grand multiparous patient labor may be %uic5
and relatively silent, and in the presence of a malpresentation, such as a transverse lie, obstructed labor may rapidly
occur.
2.2.' 3!inica! Presentation of a Patient .ith )bstrcted Labor:
Dehydration
Dehydration is due to muscular activity in the absence of ade%uate fluid inta5e. ;igns and symptoms will
include hot and dry s5in with loss of tissue turgor.
)!igria
Decreased urinary output occurs in association with the patientBs state of dehydration.
KetoLacidosis
>etabolic acidosis develops, from accumulation of lactic acid produced by the prolonged contractions of
uterine and s5eletal muscles. 7ith inade%uate caloric inta5e, endogenous tissue brea5down occurs, and the
catabolism of fat in the absence of carbohydrates leads to the production of 5etones which further increases the
acidosis. Dehydration e"aggerates the acidaemia because anions accumulate due to the diminished urinary
output. n a response to restore the acid base e%uilibrium, potassium is mobilized from the cells, which
diminishes the activity of the involuntary muscles.
!he clinical signs of 5eto.acidosis are, a rapid pulse in association with deep and rapid respiration and pyre"ia.
Acetone is present in the urine, and the bowel is fre%uently distended and atonic due to hypo5alemia.
Sepsis
nfection that is fre%uently established by the time.prolonged labor has reached the stage of obstruction,
particularly if the membranes have been ruptured for a long time. !he introduction of pathogens often occurs
with un.sterile vaginal e"aminations or manipulations. 3ven in the absence of vaginal interventions, infection
will develop in the birth canal in association with prolonged obstructed labor.
!he clinical signs of infection are purulent vaginal discharge, pyre"ia and tachycardia. n advanced cases,
infections due to gas.forming organisms may produce a crac5ling sensation when the uterus is palpated.
7hen the fetus has been dead for several days, significant gas may be produced from putrefaction and the
uterus becomes distended and tympanitic. !he terminal signs of severe intrapartum infection are septic shoc5
with circulatory collapse, hypotension, a rapid thready pulse with subnormal temperature.
State of the Uters
n multigravid, the uterus reacts to obstruction by fre%uent and stronger contractions of the upper segment.
>eanwhile, the lower segment continues to retract and already thinned by circumferential dilatation in the first stage
of labor, elongates and becomes progressively thinner. As the contractions continue, progressive retraction and
thinning of the lower segment continues and the junction ring between the lower and upper segment rises
progressively, often up to the level of the umbilicus. !his is called a pathological ring or 9andlBs Ring.
n the primigravid patient, obstruction will usually occur before full dilatation. f the obstruction is neglected the
following se%uence of events will occur,
+rolonged uterine activity may lead to reduced intervillous blood flow and fetal asphy"ia
$etal trauma associated with operative vaginal delivery
Avascular pressure necrosis from the fetal presenting part. !his develops in a ring formation at the
obstruction site leading to sloughing of the lower uterine segment and cervi".
+alpation of the uterus and observation of contractions provides important information. n the early stages of
obstruction the uterus may contract vigorously and fre%uently, with little rela"ation between contractions. !his is
followed by a continuous spasm when the uterus is hard, uniformly conve", and tender to pressure . particularly
over the distended lower uterine segment. !he patient is usually not in constant pain but feels continuous discomfort.
n obstructed labor, asphy"ia is li5ely to have caused intra.uterine fetal death by the time the patient presents for
treatment. !he asphy"ia results from interference with placental e"change of gas between fetus and mother through
the mechanism of strong repetitive uterine contractions over a long period of time or the development of a
contracted uterus.
*ptred Uters
'
!he clinical findings may vary from mild and non.specific to an obvious clinical crisis and abdominal
catastrophe. !he following signs and symptoms of impending, or early, uterine rupture are not consistent
but can aid early detection,
. +ersistent lower uterine segment pain and tenderness between contractions
. ;welling and crepitus of lower uterine segment
. Naginal bleeding
. >aternal tachycardia, hypotension and syncope
. 8aematuria
. $etal heart rate abnormalities, tachycardia, variable and late deceleration. !his is the most reliable
warning sign.
!he classic signs and symptoms of complete uterine rupture are,
. ;udden onset of tearing abdominal pain
. Cessation of uterine contractions
. Naginal bleeding
. Recession of the presenting part
. Absent fetal heart
. ;igns of intra.abdominal hemorrhage associated with hypovolaemic shoc5.
!he lower uterine segment may rupture with few dramatic signs and symptoms. !he thin avascular scar of a
previous lower uterine segment cesarean section may rupture with little bleeding and labor continue uneventfully.
rupture of the uterus becoming apparent in the post partum period.
State of the 2!adder
During labour, the bladder is normally displaced out of the pelvis and becomes palpable above the
symphysis pubis. Compression between the bac5 of the symphysis and the presenting part may prevent the
patient from emptying her bladder and ma5e catheterisation impossible. !he bladder forms a tender
swelling above the symphysis. !his overlies the stretched lower uterine segment, and the transverse
depression at the junction of the superior border of the bladder and the lower segment of the uterus may be
confused with a pathological retraction ring.
+rolonged compression traumatizes the bladder, so blood stained urine is a fairly constant feature of
obstructed labor but does not necessarily mean the uterus has ruptured.
7agina! Findings
Obstructed labor often produces oedema of the lower vagina and vulva. Associated sepsis often leads to a
thic5 offensive vaginal discharge. 9leeding is of significant concern, as it usually indicates the uterus has
ruptured.
3ervica! Findings
n cephalic presentations full cervical dilation will usually occur as the moulded fetal head is driven down
through the cervi". 7ith shoulder or compound presentations, a rim of cervi" usually persists because the
presenting part is arrested at a higher level.
9y the time obstruction has occurred, the caput succedaneum ma5es identification of the presentation and
position very difficult. n verte" presentations, a large caput on the ape" of an e"tremely molded head may
reach the outlet when the greatest diameter is still above the brim. %hereforeI &ore re!iance sho!d be
p!aced on the abdo&ina! findings .hen deciding the !eve! or station of the head.
3o&p!ications of )bstrcted Labor
0aterna!
. Ruptured &terus
. Nesico.Naginal $istulae (NN$)
. Recto.Naginal $istulae (RN$)
. +ueperal sepsis
3"tensive sloughing heals by fibrosis leading to almost complete stenosis of the vagina and dyspareunia6
apareunia
Osteitis pubis . infection of pubic bone after damage to the periosteum and superficial corte" by pressure
necrosis
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor #
Feta!
. Asphy"ia 6 cerebral palsy
. :eonatal sepsis
. Death
2.2./ %reat&ent
Prevention L n most cases, obstructed labor can be prevented by,
. Aood nutrition in childhood
. +romotion of appropriate and accessible antenatal care with health care providers trained in history and
physical e"amination s5ills
. &se of a partogram in the health unit when the patient is in labor
. !he development of appropriate and timely referral systems.
%he standard procedre for obstrcted !abor is cesarean section .hen the diagnosis has been &ade.
Pro!onged or neg!ected obstrcted !abor (uterus intact)
2. f the fetus is still alive . !he patient should be prepared for delivery with simultaneously attention to
the se%uelae of prolonged labor.
. $luid electolyte imbalance
. Control of infections with broad spectrum antibiotics and tetanus prophyla"is
>ethod of delivery,
. Nacuum in cases of mild disproportion
. $orceps, which will re%uire special s5ills for mid cavity operations
. ;ymphysiotomy (see Appendi" 4)
4. 7ith a dead fetus . f the fetus is dead, destructive operations may be considered, particularly if the
motherBs condition is morbid. Resuscitation of the mother is essential before proceeding with a
destructive procedure. !his resuscitation should include,
. Correction of fluid and electrolyte imbalance
. Control infection
. 9e prepared to prevent6treat post partum hemorrhage
*ptred Uters
/

2. +rompt management of hypovolaemia
4. *aparotomy,
. Remove fetus and placenta
-. ;ecure hemostasis ,
. Deliver the uterus out of the abdominal incision. AssistantBs hands may hold the uterus and with fingers
and thumbs occlude the uterine vessels.
. Control the bleeding edges of the uterine laceration with ring forceps.
. >anual compression of the aorta will often enable the surgeon to identify the e"tent of the lacerations in
the uterus.
. &terine artery ligation should be considered to reduce blood loss before proceeding to definitive surgery.
. nternal iliac artery ligation may be necessary to control bleeding in the base of the broad ligament.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !
9efore carrying out any surgical procedures on major vessels, identification of the course of the uretery should be
underta5en in order to avoid ureteric injury. !he integrity of the bladder should always be carefully reviewed, as the
bladder wall may fre%uently be involved in a lower uterine segment rupture.
;urgical Options,
!he choice of operative procedure is dependant on a number of factors including the patientBs condition, type of
rupture, facilities available, and e"perience of the surgeon.
1
. !otal hysterectomy
. ;ubtotal hysterectomy
. .*aceration repair and tubal ligation
. *aceration repair alone
Destructive +rocedures
. Craniotomy
. Decapitation
. 3visceration
. Cleidotomy
n a series reported by Ra5sha Anura on -- patients who underwent destructive operations, craniotomy was the most
common destructive procedure and the main indication was hydrocephalus.
1
!he performance of destructive fetal operation will depend on local facilities and e"perience.
9efore performing any destructive procedure, it is important to ensure the bladder is empty. !he aim of the
treatment is to deliver the mother by the safest possible method. !he operative vaginal delivery and destructive
procedures must be performed in an operating theatre where a set of laporatomy instruments are available for
immediate use.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # "
APPE()*+ 1A
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # #
;ource, 7orld 8ealth Organization. J+reventing +rolonged *abour, A practical guide. !he +artograph. 2II/
78O6$836>;>6I-.I
APPE()*+ 1, 1
%he Partograph: UserMs ,ide
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # $
+ote: %he contents of this appendiD has been ta:en fro& the fo!!o.ing doc&ent: W5)I N%he Partograph
4 Part 66: User$s 0ana!O fro& Preventing Prolonged Labour: A Practical Guide Series. 1@@/ 8W5)
doc&ent W5)PF5(P0S0P@'.@1. 6t represents bt part of the infor&ation covered in the origina!
doc&ent.
1.,enera! *e&ar:s
!his Pdocument6 is designed to teach the use of the partograph in the management of labour. t does not set out to
teach the principles and physiology of labour.
!he principles behind the partograph, particularly the partograph described in this series with its pre.drawn alert and
action lines, are described in +rinciples and ;trategy (78O document 78O6$836>;>6I-.I). t is assumed that a
tutor wor5ing with this [document] for teaching purposes will have ac%uired a wor5ing 5nowledge of these
principles and can pass this information on to the trainees as appropriate. Conse%uently, this [document]
concentrates on the practical aspects of using the partograph as a managerial tool in labour and not on theoretical
aspects.
2. 6ntrodction for Users
!his [document] describes the use of the partograph as a tool to help in the management of labour. A partograph is
used to record all observations made on a woman in labour. ts central feature is a graph, where dilatation of the
cervi" as assessed by vaginal e"amination is plotted. 9y noting the rate at which the cervi" dilates, it is possible to
identify women whose labours are abnormally slow and who re%uire special attention. !hese women are at ris5 of
developing prolonged and obstructed labour due to cephalopelvic disproportion (C+D), which may lead to serious
problems, such as ruptured uterus and death of the fetus. Other problems that may result from slow progress in
labour include postpartum haemorrhage and infection.
9y helping to identify at an early stage those women whose labour is slow, the partograph should prevent some of
these problems. t is also a very clear way of recording all labour observations on one chart, ma5ing it easy to detect
any other abnormalities.
'. Who Sho!d +ot 5ave a Partograph in Labor
9efore describing how to use the partograph, it is important to realise that it is a tool for &anaging !abor on!y. t
does not help to identify other ris5 factors which may have been present before labour started.
)n!y start a partograph .hen yo have chec:ed that there are no co&p!ications of the pregnancy
that re-ire i&&ediate action.
/. )bBectives
After studying this [document], the physician and midwifery personnel should be able to,
&nderstand the concept of the partograph.
Record the observations accurately on the partograph.
&nderstand the difference between the latent and the active phases of labour.
nterpret a recorded partograph and recognize any deviation from the norm.
>onitor the progress of labour, recognize the need for action at the appropriate time, and decide on timely
referral.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # %
3"plain to mothers and other members of the community the significance of the partograph.
<. )bservations 3harted on the Partograph
Observations and recordings will be e"plained in the following se%uence,
%he progress of !abor
Cervical dilatation
Descent of the fetal head
o Abdominal palpation of fifths of head felt above the pelvic brim
&terine contractions
o $re%uency per 20 minutes
o Duration (shown by differential shading)
%he feta! condition
$etal heart rate
>embranes and li%uid
>oulding of the fetal s5ull
%he &aterna! condition
+ulse, blood pressure and temperature
&rine (volume, protein, acetone)
Drugs and N fluids
O"ytocin regime
<.1 %he Progress of Labor
<.1.1 Latent and active phases of !abor
!he first stage of labour is divided into the !atent and active phases.
Starting the Partograph:
A partograph chart must only be started when a woman is in labour. <ou must be sure that she is contracting
enough to start the partograph.
6n the !atent phase
Contractions must be 2 or more in 20 minutes, each lasting 40 seconds or more.
6n the active phase
Contractions must be 4 or more in 20 minutes, each lasting 40 seconds or more.
<.1.2 3ervica! di!atation
!he rate of cervical dilatation changes from the latent to the active phase of labour.
!he !atent phase (slow period of cervical dilatation) is from 0.4 cm with a gradual
shortening of the cervi".
!he active phase (faster period of cervical dilatation) is from - cm to 20 cm (full
cervical dilatation).
n the centre of the partograph is a graph. Along the left side are numbers 0.20 against s%uares, each s%uare
represents 2 cm dilatation. Along the bottom of the graph are numbers 0.4/, each s%uare represents 2 hour.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # &
Dilatation of the cervi" is measured in centimetres (cm)F
!he dilatation of the cervi" is plotted (recorded) with an JQK. !he first vaginal e"amination, on admission, includes
a pelvic assessment and the findings are recorded. !hereafter, vaginal e"aminations are made every / hours, unless
contraindicated. 8owever, in advanced labour, women may be assessed more fre%uently, particularly multipara.
(Da&p!e: P!otting cervica! di!atation .hen ad&ission is in the active phase.
*oo5 at $ig. .4. n the section labelled active phase there is an JalertK line, a straight line from - R 20 cm. 7hen a
woman is admitted in the active phase, the dilatation of the cervi" is plotted on the alert line and the cloc5 time
written directly under the Q in the space for time.
6f progress is satisfactoryI the p!otting of cervica! di!atation .i!! re&ain on or to the !eft of the a!ert !ine.
)bservations on Fig. 66.2
Dilation of the cervi" was / cm, active phase.
Dilation is plotted on the alert line at / cm.
!he time of admission was 21,00.
At 2L,00 dilatation was 20 cm.
!ime in the first stage of labour in hospital was only 4 hours.
(Da&p!e : P!otting cervica! di!atation .hen ad&ission is in the latent phase.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !'
*oo5 at $ig. .-. !he latent phase normally should not ta5e longer than E hours. 7hen admission is in the latent
phase, dilatation of the cervi" is plotted at 0 time and vaginal e"amination made every / hours.
)bservations on Fig. 66.'
Admission was at I,00 and the cervi" was 2 cm dilated.
At 2-,00 the cervi" was 4 cm dilated.
At 2L,00 the cervi" was - cm dilated when she entered the active phase of labour.
At 40,00 the cervi" was 20 cm (fully dilated).
*atent phase lasted E hours and active phase lasted - hours.
>. Abnor&a! Progress of Labor
>.1 Pro!onged Latent Phase
f a woman is admitted in labour in the latent phase (less than - cm dilated) and remains in the latent phase for the
ne"t E hours, progress is abnormal and she must be transferred to a hospital for a decision about further action.
!his is why there is a heavy line drawn on the partograph at the end of E hours of the latent phase.
(Da&p!e: P!otting pro!onged !atent phase
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !1
*oo5 at $ig. .24.
)bservations on Fig. 66.12
On admission at L,00, the head was 161 above the pelvic brim and the cervi" was 2 cm dilated. !here
were 4 contractions in 20 minutes, each lasting 40./0 seconds.
After / hours at 22,00, the head was /61 above the pelvic brim and the cervi" was 4 cm dilated. n the
last 20 minutes of that half.hour, there were 4 contractions, each lasting between 40 and /0 seconds.
$our hours later at 21,00, the head was still /61 above the pelvic brim and the cervi" was still 4 cm
dilated. !here were - contractions in 20 minutes, each lasting between 40 and /0 seconds.
!he length of the latent phase was E hours in the unit.
>.2 Pro!onged Active Phase
>.2.1 0oving to the right of the a!ert !ine
n the active phase of labour, potting of cervical dilatation will normally remain on, or to the left of the alert line.
9ut some will move to the right of the alert line and this warns that labour may be prolonged.
7hen the dilatation moves to the right of the alert line and if ade%uate facilities are not available to deal with
obstetrical emergencies, the woman must be transferred to a hospital unless she is near delivery. 9y transferring her
at this time, it allows time for the woman to be ade%uately assessed for appropriate intervention if she reaches the
action line.
>.2.2 At the action !ine
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !2
!he action line is / hours to the right of the alert line. f a womanBs labour reaches this line, a decision must be
made about the cause of the slow progress, and appropriate action ta5en. !his decision and action must be ta5en in a
hospital with facilities to deal with obstetric emergencies.
(Da&p!e: P!otting di!atation that crosses the a!ert !ine and reaches the action !ine
*oo5 at $ig. .2-
)bservations on Fig. 66.1'
At E,00 the cervi" is - cm dilated on the alert line. !he woman may remain in the health unit.
At 24,00 the cervi" is @ cm dilated and the graph has moved to the right of the alert line. !he woman
must be transferred to an institution with facilities for obstetric interventions.
At 2@,00 the cervi" is L cm dilated and the graph is on the action line. A decision must be made on
what action needs to be ta5en
)bservations on Fig. 66.1/
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !
!he shaded area between alert and action lines in the active phase and beyond E hours in the latent
phase would re%uire referral from a health centre and6or e"tra vigilance in hospital.
Points to *e&e&ber:
2. All women whose cervicograph moves to the right of the alert line must be transferred and managed in
an institution with ade%uate facilities for obstetric interventions, unless delivery is near.
4. At the action line the woman must be carefully reassessed for the reason for lac5 of progress and a
decision made on further management.
F. 0anage&ent of Labor
!he following is the protocol for labour management used in a large multicentre trail of the 78O partograph. !his
protocol achieved e"cellent results and its use in conjunction with the partograph is recommended, although local
adaptation may be made.
F.1 +or&a! Latent and Active Phases
(*atent phase is less than E hours and progress in active phase remains on or left of alert line.)
Do not augment with o"ytocin or intervene unless complications develop.
Artificial rupture of membranes (AR>),
o +o A*0 in the latent phase.
o AR> at any time in the active phase.
F.2 2et.een A!ert and Action Lines
'n a health centre* the woman must be transferred to hospital with facilities for caesarean section,
unless the cervi" is almost fully dilated.
AR> may be performed if the membranes are still intact, and observe labour progress for a short
period of time before transfer.
'n hospital, perform AR> if membranes intact, and continue routine observations.
F.' At or 2eyond Active Phase Action Line
$ull medical assessment.
Consider intravenous infusion6bladder catheterization6analgesia.
Options,
o Delivery (normally caesarean section), if fetal distress or obstructed labour.
o O"ytocin augmentation by intravenous infusion, if no contraindications.
o ;upportive therapy only (if satisfactory progress now established and dilatation could be
anticipated at 2cm6hour or faster).
$urther review (in cases of continuing in labour),
o Naginal e"amination after - hours,M then in 4 more hoursM then in 4 more hours.
o $ailure to ma5e satisfactory progress, measured as a cervical dilatation rate of less than
2cm6hour between any of these e"aminations, means delivery is indicated.
o $etal heart while on o"ytocin infusion must be chec5ed at !east every ha!fLhor.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !!
F./ Pro!onged Latent Phase 8>= hors1
$ull medical assessment.
Options,
. :o action (woman not in labour, abandon partograph)
. Delivery by caesarean section (if fetal distress or factors li5ely to lead to obstruction or
other medical complications necessitating termination of labour.)
. AR> ' o"ytocin (if contraction pattern and6or cervical assessment suggest continuing
labour).
$urther review (in cases of continuing in labour),
. Continue vaginal e"aminations once every / hours, up to 24 hours.
. f not in active phase after E hours of o"ytocin, delivery by caesarean section.
. f active phase is reached within or by E hours but progress in active phase is < 2cm6hour,
delivery by caesarean section may be considered.
. >onitor fetal hearth every half.hour while on o"ytocin.
F.< Frther +otes
)Dytocin
A local regime may be usedM the 78O trial did not specify a particular o"ytocin regime. O"ytocin should be
titrated against uterine contractions and increased every half.hour until contractions are - or / in 20 minutes, each
lasting /0.10 seconds. t may be maintained at that rate throughout the second and third stages of labour.
;top o"ytocin infusion if there is evidence of uterine hyperactivity and6or fetal distress.
O"ytocin was used in women of all parities in the multicentre trial. 8owever, it must be used with caution in
multiparous women and rarely, if at all, in women of para 1 or more.
0e&branes
f membranes have been ruptured for 24 hours or more, antibiotics should be given.
Feta! Distress
n a health centre, transfer to hospital with facilities for operative delivery.
'n hospital, immediate management,
o ;top o"ytocin.
o !urn woman on left side.
o Naginal e"amination to e"clude cord prolapse and observe amniotic fluid.
o Ade%uate hydration.
o O"ygen, if available.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !"
APPE()*+ 2
SE0P5ES6)%)0E
!+G, recogni-es that symphysiotomy may $e a life saving procedure which can $e successfully used in
circumstances where ,aesarean !ections are not availa$le. 't is for this reason that the procedure is included in
the A.A() 'nternational /rogram )anual. !+G, leaves it to the /rogram0s 1aculty in each country whether
to include this topic in the curriculum.
;ymphysiotomy results in a temporary increase in pelvic diameter (up to 4 cm) by surgically dividing the ligaments
of the symphysis under local anaesthesia. !his procedure should be carried out only in combination with vacuum
e"traction. ;ymphysiotomy in combination with vacuum e"traction is a life.saving procedure in areas where
caesarean section is not feasible or immediately available. ;ymphysiotomy leaves no uterine scar and the ris5 of
ruptured uterus in future labours is not increased.
!hese benefits must, however, be weighed against the ris5s of the procedure. Ris5s include urethral and bladder
injury, infection, pain and long.term wal5ing difficulty. ;ymphysiotomy should, therefore, be carried out only when
there is no safe alternative.
Review for indications,
. contracted pelvisM
. verte" presentationM
. prolonged second stageM
. failure to descend after proper augmentationM
. A:D failure or anticipated failure of vacuum e"traction alone.
Review conditions for symphysiotomy,
. fetus is aliveM
. cervi" is fully dilatedM
. head at R4 station or no more than -61 above the symphysis pubisM
. no over.riding of the head above the symphysisM
. caesarean section is not feasible or immediately availableM
. the provider is e"perienced and proficient in symphysiotomy.
Review general care principles.
+rovide emotional support and encouragement. &se local infiltration with lignocaine.
As5 two assistants to support the womanBs legs with her thighs and 5nees fle"ed. !he thighs should be
abducted no more than /1 from the midline.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !#
Abdction of the thighs &ore than /< fro& the &id!ine &ay case tearing of the
rethra and b!adder.
Figre 1 L Position of the .o&an for the sy&physioto&y
+erform a mediolateral episiotomy. f an episioto&y is a!ready present, enlarge it to minimize stretching
of the vaginal wall and urethra.
nfiltrate the anterior, superior and inferior aspects of the symphysis with lignocaine 0.1O solution.
:ote, Aspirate (pull bac5 on the plunger) to be sure that no vessel has been penetrated. f b!ood is retrned in the
syringe .ith aspiration, remove the needle. Rechec5 the position carefully and try again. :ever inject if blood is
aspirated. %he .o&an can sffer seiCres and death if 67 inBection occrs.
At the conclusion of the set of injections, wait 4 minutes and then pinch the incision site with forceps. f
the .o&an fee!s the pinch, wait 4 more minutes and then retest.
nsert a firm catheter to identify the urethra.
Apply antiseptic solution to the suprapubic s5in.
7earing high.level disinfected gloves, place an inde" finger in the vagina and push the catheter, and with it
the urethra, away from the midline.
Figre 2 L Pshing rethra to one side after inserting the catheter
7ith the other hand, use a thic5, firm.bladed scalpel to ma5e a vertical stab incision over the symphysis.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !$
AnaesthetiCe ear!y to provide sfficient ti&e for effect.
Ceeping to the midline, cut down through the cartilage joining the two pubic bones until the pressure of the
scalpel blade is felt on the finger in the vagina.
Cut the cartilage downwards to the bottom of the symphysis, then rotate the blade and cut upwards to the
top of the symphysis.
Once the symphysis has been divided through its whole length, the pubic bones will separate.
Figre ' L Dividing the carti!age
After separating the cartilage, remove the catheter to decrease urethral trauma.
Deliver by vacuum e"traction. Descent of the head causes the symphysis to separate 2 or 4 cm.
After delivery, catheterize the bladder with a self.retaining bladder catheter.
!here is no need to close the stab incision unless there is bleeding.
P)S%LP*)3(DU*( 3A*(
f there are signs of infection or the woman crrent!y has a fever, give a combination of antibiotics until
she is fever.free for /E hours,
. ampicillin 4 g N every @ hoursM
. +*&; gentamicin 1 mg65g body weight N every 4/ hoursM
. +*&; metronidazole 100 mg N every E hours.
Aive appropriate analgesic drugs.
Apply elastic strapping across the front of the pelvis from one iliac crest to the other to stabilize the
symphysis and reduce pain.
*eave the catheter in the bladder for a minimum of 1 days.
3ncourage the woman to drin5 plenty of fluids to ensure a good urinary output.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !%
3ncourage bed rest for L days after discharge from hospital.
3ncourage the woman to begin to wal5 with assistance when she is ready to do so.
f !ongLter& .a!:ing diffic!ties and pain are reported (occur in 4O of cases), treat with physical therapy.
ALARM INTERNATIONAL # Chapter 2 - Management of Labor/Obstructed Labor # !&
2
3hapter (ndnotes
+hilpott, R.8. Obstructed *abour. Clinical Obstetric Aynaecology. 2IE4, I.
4
>urray, C..*, *opez, A.D (3ds). 8ealth Dimensions of ;e" and Reproduction. 78O68arvard ;chool of +ublic 8ealth 6
7orld 9an5 2IIEMAlobal 9urden of Disease and njury, Nol ;9: 0.@L/.-E--1./.
-
9as5et, !.$. 3ssential >anagement of Obstetric 3mergencies. Clinical +ress *imited, 2III.
/
9as5et, !.$. 3ssential >anagement of Obstetric 3mergencies. Clinical +ress *imited, 2III.
1
;ource, 7orld 8ealth Organization. >anaging Complications in +regnancy and Childbirth, A guide for midwives and
doctors.78O6R8R600.L, 4000, ;ection -, +rocedures. pp. +.1-.+1@.

CH02

Enviado por

Dados do documento

Direitos autorais

Formatos disponíveis

Compartilhar este documento

Compartilhar ou incorporar documento

Opções de compartilhamento

Você considera este documento útil?

Este conteúdo é inapropriado?

Direitos autorais:

Formatos disponíveis

CH02

Enviado por

Direitos autorais:

Formatos disponíveis

SECOND EDITION OF THE ALARM INTERNATIONAL PROGRAM SYLLABUS

Você também pode gostar