THE PARTOGRAPH

1. 1 THE PARTOGRAPH

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3. 3 INTRODUCTION Prolonged labour is a leading cause of death among mothers and newborns in the developing world. Etiology: Cephalo Pelvic Disproportion Uterus does not contract sufficiently Complications : obstructed labour, dehydration, exhaustion, rupture of the uterus, maternal infection, vesico-vaginal fistula, hemorrhage and neonatal infection.

4. 4 INTRODUCTION The partograph is a tool uses to record the information from the history and physical examination of the woman in labour. It helps to follow and interpret the progress of women�s labour through recording of cervical dilatation, descent of fetal head and contractions. Also help to monitor maternal and fetal wellbeing. Usefull to manage the labour of women with or without complications. THE PARTOGRAPH IS NOT A REPLACEMENT OF LABOUR CARE

5. 5 labour care involves more than a partograph. It involves individual care and attention for each woman in labour.

6. 6 Partograph Label with patient identifying information Note fetal heart rate, color of amniotic fluid, presence of moulding, contraction pattern, medications given Plot cervical dilation Alert line starts at 4 cm--from here, expect to dilate at rate of 1 cm/hour Action line: If patient does not progress as above, action is required The partograph is a useful tool for monitoring the progress of labour. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labour. At the alert line, the onset of the active phase of labour (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labour.The partograph is a useful tool for monitoring the progress of labour. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labour. At the alert line, the onset of the active phase of labour (4 cm), the patient is expected to reach full dilation at the rate of 1 cm/hour. At the action line, which is 4 hours to the risk of the alert line, the practitioner is signaled to take action if the patient is not following the expected course of labour.

7. 7 Use of Partograph: Best Practice WHO recommends using the partograph to monitor all women during labour. The partograph is a tool, not an end in itself. When used effectively, the partograph: provides a graphic representation of labour progress and the condition of the mother and fetus guides early detection of prolonged or obstructed labour informs decision-making in the management of labour Prolonged and/or obstructed labour is one of the top five causes of maternal mortality. The partograph is a useful tool for monitoring the progress of labour. However, in many countries today where its use has been mandated without proper training, the partograph serves only as a record of labour (often completed after the baby is born) and not as a tool to guide decision-making. Using the partograph effectively helps to ensure careful monitoring of the woman in labour, avoid unnecessary interventions, and recognize and respond to complications in a timely manner---all of which can help prevent maternal and neonatal morbidity or mortality. OPTIONAL: See Slide 41 for a more detailed description and graphic image of the partograph. Prolonged and/or obstructed labour is one of the top five causes of maternal mortality. The partograph is a useful tool for monitoring the progress of labour. However, in many countries today where its use has been mandated without proper training, the partograph serves only as a record of labour (often completed after the baby is born) and not as a tool to guide decision-making. Using the partograph effectively helps to ensure careful monitoring of the woman in labour, avoid unnecessary interventions, and recognize and respond to complications in a timely manner---all of which can help prevent maternal and neonatal morbidity or mortality. OPTIONAL: See Slide 41 for a more detailed description and graphic image of the partograph.

8. 8 STARTING THE PARTOGRAPH Who should not have a partograph ? Antepartum hemorhage Eclampsia Fetal distress Malpresentation CPD= cepalopelvix disproporsi All women in labour must be screened for such special problem

9. 9 STARTING THE PARTOGRAPH The partograph must only be started when a woman is in a labour: In the latent phase : Contractions must be 2 or more in 10 minutes, each lasting 20 seconds or more. In the active phases: Contractions must be 3 or more in 10 minutes, each lasting 40 seconds or more.

10. 10 HOW TO USE THE PARTOGRAPH When a woman�s admitted in labour, you must evaluate her condition and the condition of her baby. Start the partograph by writing a woman�s name and other admission information. Write the time of admission

11. 11 HOW TO USE THE PARTOGRAPH (cont.)

12. 12 PARTS OF THE PARTOGRAPH Progress of labour Fetal Condition Maternal Condition

13. 13 A. Progress of labour Cervical dilatation Descent of the presenting fetal head Uterine Contractions

14. 14 CERVICAL DILATATION The first stage of labour is divided into the latent and active phases The latent phase : Slow period of cervical dilatation from 0 � 2 cm with a gradual shortening of the cervix. Should not more than 8 hours The active phase: Faster period of cervical dilatation) is from 3 cm to 10 cm (full cervical dilatation) Normally 1 cm/hour

15. 15 RECORDING CERVICAL DILATATION ON THE PARTOGRAPH Mark hours along the bottom (horizontal) axis. The time of admission is written in front of the first square Find the area along the left side labeled : Cervix Cervical dilatation mark as �X�, each square represent 1 cm dilatation

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17. 17 RECORDING CERVICAL DILATATION ON THE PARTOGRAPH On the graph, Three dark line are drawn: Latent Phase drawn along the line for 3 cm in dilatation, from time 0 to 8 hours Alert is drawn beginning at 3 cm in dilatation from time 8 hours extending to 10 at 15 hours. This line increases 1 cm per hour Action is drawn 4 hours to the right of the alert line (from 12 to 19 hours for 3 to 10 cm of dilatation

18. 18 FREQUENCY OF VAGINAL EXAMINATION Every 4 hours More Frequent : - Discomfort for the mother - Introducing infection Less frequent : Delay in diagnosis slow progress in labour

19. 19 OTHER SIGNS OF PROGRESS IN LABOUR Although cervical dilatation is the most important sign of progress in labour, other important signs are: Uterine contractions Descent of the fetal head

20. 20 RECORDING HEAD DESCENT ON THE PARTOGRAPH Assess the level of the fetal head abdominally before every vaginal examination Note the number of fifth that can be felt above the pelvis Record the level by an �O� on the partograph. This means that every �X� mark for cervical dilatation there is must be an �O� mark for level of fetal head On the active phase, �X� and �O� should be transferred to the alert line

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22. 22 DESCENT OF THE HEAD

23. 23 Recording fetal descent

24. 24 UTERINE CONTRACTIONS Measured more often than cervical dilatattion and fetal head descent Every hour in the latent phase and every � hour in the active phase Assess contractions in the last 10 minutes of each hour/ half-hour Count all the contractions (frequency and duration) in that 10 minutes Fill in one box at the right time on the partograph

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26. 26 Three possible ways the duration of contractions can be shaded.

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29. 29 FETAL CONDITION Fetal Heart Rate Color and amount of liqour Molding of fetal skull

30. 30 Recording fetal condition Fetal Heart: Record every half-hour Liqour: record every 4 hours at the time of vaginal examination, but anytime if the liquor changes Moulding: Note and record at each vaginal examination

31. 31 Recording fetal condition

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36. 36 MATERNAL CONDITION Pulse and blood pressure Temperature Urine test and volume Medications given Fluid intake

37. 37 MATERNAL CONDITION

38. 38 Recording maternal condition

39. 39 Example: Mother condition

40. 40 POINTS TO REMEMBER Time of admission is 0 time, when the woman in the latent phase of labour When the active phase of labour begins, all recordings are transferred, plotting the cervical dilatation on the alert line. If the women comes in the active phase of labour, recording of cervical dilatation starts on the alert line. When the progress of labour is normal, plotting of the cervical dilatation remains on the alert line or to the left of it.

41. 41 ABNORMAL PROGRESS OF LABOUR Prolonged Latent Phase If a woman is admitted in labour in the latent phase (less than 3 cm dilated) and remains in the latent phase for the next 8 hours, progress -is abnormal and she must be transferred to a hospital for a decision about further action: This is why there is a heavy line drawn on the partograph at the end of 8 hours of the latent phase:

42. 42 Plotting prolonged latent phase

43. 43 Observations on partograph above: On admission at 7:00, the head was 5/5 above the pelvic brim and the cervix was 1 cm dilated. There were 2 contractions in 10 minutes, each lasting 20-40 seconds. After 4 hours at 11:00, the head was 4/5 above the pelvic brim and the cervix was 2 cm dilated. In the last 10 minutes of that half-hour, there, were 2 contractions, each lasting between 20 end 40 seconds. Four hours later at 15:00, the head was still 4/5 above the pelvic brim and the cervix was still 2 cm dilated. There were 3 contractions in 10 minutes,each lasting between 20 and 40 seconds. The length of the latent phase was 8 hours in the unit.

44. 44 Support of Woman Give woman as much information and explanation as she desires Provide care in labour and childbirth at a level where woman feels safe and confident Provide empathic support during labour and childbirth Facilitate good communication between caregivers, the woman and her companions Continuous empathetic and physical support is associated with shorter labour, less medication and epidural analgesia and fewer operative deliveries Data show that emotional and physical support reduce the complications of labour, such as the need of analgesia and operative interventions. Data show that emotional and physical support reduce the complications of labour, such as the need of analgesia and operative interventions.

45. 45 Support from female relative improves labour outcomes Skilled management of labour using a partograph, a simple chart for recording information about the progress of labour and the condition of a woman and her baby during labour, is key to the appropriate prevention and treatment of prolonged labour and its complications. Following the recommendation of the World Health Organization (WHO), the Maternal and Neonatal Health (MNH) Program promotes the use of the partograph to improve the management of labour and to support decision-making regarding interventions. When used appropriately, the partograph helps providers identify prolonged labour and know when to take appropriate actions. Data show that non-supine positions result in many more favorable outcomes, such as a shorter second stage, less interventions, such as episiotomy or vacuum, and less pain for the woman. They contribute to her overall comfort.Data show that non-supine positions result in many more favorable outcomes, such as a shorter second stage, less interventions, such as episiotomy or vacuum, and less pain for the woman. They contribute to her overall comfort.

46. 46 Normal labour and Childbirth: Conclusion Have a skilled attendant present Use partograph Use specific criteria to diagnose active labour Restrict use of unnecessary interventions Use active management of third stage of labour Support woman�s choice for position during labour and childbirth Provide continuous emotional and physical support to woman throughout labour

47. 47 Refferences: World Health Organization: Maternal health and Safe Motherhood Programme Division of Family Health; Preventing Prolonged Labour: a practical guide. The Partograph Part II, Users Manual Maternal Neonatal Health : Best Practise, The Partograph Healthy Mother & Healthy Newborn Care : Exercise 4-5. Using the Partograph to monitor labour.

48. 48 References Carroli G and J Belizan. 2000. Episiotomy for vaginal birth (Cochrane Review), in The Cochrane Library. Issue 2. Update Software: Oxford. Eason E et al. 2000. Preventing perineal trauma during childbirth: A systematic review. Obstet Gynecol 95: 464�471. Gupta JK and VC Nikodem. 2000. Woman�s position during second stage of labour (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. Lauzon L and E Hodnett. 2000. Caregivers' use of strict criteria for diagnosing active labour in term pregnancy (Cochrane Review), in The Cochrane Library. Update Software: Oxford. Ludka LM and CC Roberts. 1993. Eating and drinking in labour: A literature review. J Nurse-Midwifery 38(4): 199�207. Madi BC et al. 1999. Effects of female relative support in labour: A randomized control trial. Birth 26:4�10. Neilson JP. 1998. Evidence-based intrapartum care: evidence from the Cochrane Library. Int J Gynecol Obstet 63 (Suppl 1): S97�S102. World Health Organization Safe Maternal Health and Safe Motherhood Programme. 1994. World Health Organization partograph in management of labour. Lancet 343 (8910):1399�1404. World Health Organization (WHO). 1999. Care in Normal Birth: A Practical Guide. Report of a Technical Working Group. WHO: Geneva.