PARTOGRAPH

1. PARTOGRAPH DR SHASHWAT JANI M.s. ( gynec ) Assist. Prof., Smt. N.H.L. MEDICAL COLLEGE, AHMEDABAD. Mobile : +91 99099 44160. E- mail : drshashwatjani@gmail.com

2. WHY MONITOR? The intrapartum period is probably the most dangerous and traumatic period – a time associated with a high mortality and morbidity for both mother and child. Maternal and fetal monitoring are essential to pick up problems early and thus institute timely intervention. Eternal alertness for abnormalities essential – “a labour is only said to be normal after it is over”

3. INTRODUCTION A partograph is a composite graphical record of the observations made of a woman in labour on a single sheet of paper. It was developed and extensively tested by the World Health Organization (WHO 1994). Can serve as an “early warning system” & assist in making timely decisions on transfers (referrals), intervention (augmentation) &/or termination of pregnancy.

4. HISTORY EmanuelFriedman'spartograph - 1954 Based on observations of cervical dilatation and foetal station against time elapsed in hours from onset of labour. The time of onset of labour was based on the patient's subjective perception of her contractility. Plotting cervical dilatation against time yielded the typical Sigmoid or 'S' shaped curve, and station against time gave rise to the Hyperbolic curve.

6. Philpott and Castle – 1972 Introduced concept of "ALERT" and "ACTION" lines. Alert line was drawn at a slope of 1 centimetre/hr for nulliparous women starting at zero time i.e. time of admission . Action line drawn four hours to the right of the alert line showing that if the patient has crossed the alert line active management should be instituted within 4 hours, enabling the transfer of the patient to a specialised tertiary care centre.

8. Studd'slabour stencils - 1972 Five separate patterns representing normal labour progression were constructed. The curves were transcribed onto acrylic stencils.

9. OTHER PARTOGRAPHS Hand drawn – Paper & Pencil. Round partograph. E – partograph.

10. PARTOGRAPH

11. OBJECTIVES Early detection of abnormal progress of labour. Prevention of prolonged labour. Recognize cephalopelvic disproportion long before obstructed labour. Assist in early decision on transfer, augmentation, or termination of labour.

12. OBJECTIVES (cont..) Increase the quality and regularity of all observations of mother and fetus. Early recognition of maternal or fetal problems. Highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc). Reduce incidence of CS rate. Facilitates handover procedure.

13. COMPONENTS Part I : Patient Identification Part II : Fetal condition Part III : Progress of labour Part IV : Maternal condition Outcome ………………

14. Part I : PATIENT IDENTIFICATION Name Gravida Para Hospital number Date and time of admission Time of ruptured membranes.

15. Part II : FETAL CONDITION Monitor and assess fetal condition 1 - Fetal heart rate 2 - Liquor 3 - Moulding the fetal skull bones

16. FETAL HEART RATE • Monitor every 30 mins in latent phase. • Every 15 mins in active phase. • Every 5 mins in 2nd stage of labour. • Mark it with a dot & join the lines. Basal fetal heart rate? • < 160 beats/min =tachycardia • > 110 beats/min = bradycardia • >100beats/min = severe bradycardia

17. MEMBRANES AND LIQUOR Intact membranes ……………………………….. I Ruptured membranes + clear liquor ……………… C Ruptured membranes + meconium- stained liquor.. M Ruptured membranes + blood – stained liquor…… B Ruptured membranes + absent liquor……………. A

18. MOULDING THE FETAL SKULL BONES Moulding is an important indication of how adequately the pelvis can accommodate the fetal head. Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion. Separated bones, sutures felt easily …………….… O Bones just touching each other …………………… + Overlapping bones (reducible)…………………... ++ Severely overlapping bones (nonreducible) …….. +++

20. Part III : PROGRESS OF LABOUR Cervical dilatation Descent of the fetal head Uterine contractions Fetal position

21. This section of the partograph has as its central feature a graph with a vertical scale on the left, numbered in the ascending order from 0 to 10 (Cervical dilatation in cms). In same vertical scale – descent of the fetal head as assessed by abdominal examination. At the right in the descending order denotes the station of the fetal presenting part.

23. Horizontal scale represents hours spent in labour. Points are entered as a cross (x) for cervical dilatation & station by a dot (•). Each observation is joined to the preceding one by a straight line. The ‘S’ shaped dilatational curve is divided into a latent phase and an active phase.

24. LATENT PHASE It starts from onset of labour until the cervix reaches 3 cm dilatation. Once 3 cm dilatation is reached, labour enters the active phase. Lasts 8 hours or less. At least 2/10 min contractions. Each lasting < 20 seconds.

25. ACTIVE PHASE • Contractions at least 3 / 10 min • Each lasting < 40 seconds • The cervix should dilate at a rate of 1 cm / hour or faster. • Further subdivided into – • Acceleration phase – 2.5 – 4 cms. • Phase of maximum slope – 4 – 9 cms. • Deceleration phase – 9 – 10 cms.

27. This can also be divided into 3 functional divisions – Preparatory division – Including latent & acceleration phase. Dilatation division – Phase of maximum slope. Pelvic division – Deceleration phase.

28. ALERT LINE The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm/hour. In a normal labour, cervical dilatation should be either on the alert line or to the left of it. Moving to the right of the alert line means it falls on zone 2, it is abnormal & needs to be critically assessed.

29. ACTION LINE The action line is drawn 4 hours to the right of the alert line and parallel to it. This is the critical line at which specific management decisions must be made. When it falls in zone 3 case should be reassessed by a senior person. Decision to be made for CS or augmentation of labour.

31. CERVICAL DILATATION It is the most important information and the surest way to assess progress of labour. When progress of labour is normal and satisfactory, plotting of cervical dilatation remains on the alert line or to left of it. If a woman arrives in the active phase of labour, recording of cervical dilatation starts on the alert line.

33. CERVICAL DILATATION (cont..) When the active phase of labor begins, all recordings are transferred and start by plotting cervical dilatation on the alert line using the letters TR. Leaving the area between the transferred recording blank. The broken transfer line is not part of the process of labor. Do not forget to transfer all other findings vertically.

35. DESCENT OF THE FETAL HEAD It should be assessed by abdominal examination immediately before doing a vaginal examination, using the Rule of fifth ( Crichton method ) to assess engagement. The rule of fifth means the palpable fifth of the fetal head is felt by abdominal examination above the level of symphysis pubis. When 2/5 or less of fetal head is felt above the level of symphysis pubis, this means that the head is engaged.

37. DESCENT OF THE FETAL HEAD (cont..) By vaginal examination, the lowest part of vertex has passed or is at the level of ischial spines in absence of caput, is said to be engaged head.

38. FETAL POSITIONS Occiput transverse positions Occiput anterior positions

40. UTERINE CONTRACTIONS Palpate number of contractions in ten minutes and duration of each contraction in seconds • Less than 20 seconds: • Between 20 and 40 seconds: • More than 40 seconds:

41. Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase. Assessed by number of contractions in a 10 minutes period. Measured in seconds from the time the contraction is first felt abdominally, to the time the contraction passes off. Each square represents one contraction.

43. Part IV: MATERNAL CONDITION Assess maternal condition regularly by monitoring: Oxytocin – Amount per volume IV fluids in drops per minute, every 30 mins. Conc in upper box & dose (mIU/min) in lower box. Drugs – Any additional drugs given. IV Fluids – used.

44. Part IV: MATERNAL CONDITION Pulse – Every 30 mins & marked with a dot (•). Blood pressure – Recorded in vertical line every 4 hours & marked with arrows. Temperature – Recorded every 2 hours. Urine volume , analysis for protein and acetone – Everytime urine is passed.

46. Management of labour using the partograph

47. - Latent phase is less than 8 hours- Progress in active phase remains on or to the left of the alert line. Do not augment with oxytocin if latent and active phases go normally. No ARM in latent phase. ARM at any time in active phase.

48. Between alert and action lines • In health center, the women must be transferred to a hospital with facilities for caesarean section, unless the cervix is almost fully dilated. • Observe labor progress for short period before transfer. • Continue routine observations. • ARM may be performed if membranes are still intact.

49. At or beyond action line • Conduct full medical assessment. • Consider intravenous infusion / bladder catheterization / analgesia. • Options • - Deliver by caesarean section if there is fetal distress or obstructed labour. • - Augment with oxytocin by intravenous infusion if there are no contraindications.

50. ABNORMAL PROGRESS OF LABOR