MANAGEMENT OF LABOUR WITH PARTOGRAM

1. MANAGEMENT OF LABOUR WITH PARTOGRAM

2. OBJECTIVES At the end of this session you are expected to be able to: • Define the partogram • Explain the importance of using partogram in labour. • Describe the principles that are used to design the partogram • Describe the principles of using the partogramat the basic and comprehensive health facilities. • Describe the protocol for labour management with the WHO partogram

3. What is a partogram (partograph) ?

4. Definition The partogram Is a graph used in labour to monitor the parameters of progress of labour, maternal and fetal wellbeing, and treatment administration

6. PRACTICAL VALUE OF USING THE PARTOGRAM • Offers an objective basis for overtime monitoring the progress of labour, maternal and fetal wellbeing. • Enables early detection of abnormalities of labour • Prevention of obstructed labour and ruptured uterus.

7. PRACTICAL VALUE OF PARTOGRAMcont • Complications of obstructed labour and ruptured uterus contribute up to 30% of maternal deaths in some areas. • Proper use of partogram has proved so useful in reduction of both maternal and perinatal mortalities and morbidities

8. RECOMMENDATIONS ON THE USE OF PARTOGRAM Basedon the evidence-based reports on its effectiveness in monitoring of labour. WHO Recommends its use in all labour wards and for all women(WHO 1994) Tanzania Its use is obligatory at all levels of obstetric care

9. PRINCIPLES USED TO DESIGN THE PARTOGRAM The partogram depends on the principles that; • The latent phase should not last longer than 8 hours • The latent phase ends and active phase starts when the cervix is 3cm (4cm is sometimes used) • During active phase – the cervix should dilate at not less than 1 cm per hour

10. PRINCIPLES cont • A lag time of 4 hours is usually acceptable the slowing of labour and the need to intervene; this is the distance between alert line and the action line.

11. PRINCIPLES OF USING THE PARTOGRAM • Basic health facilities • Used to monitor labour which is expected to be normal. • Those with risk factors should already have been referred. • Referral is decided when the progress line of the cervical dilatation deviates to the right of an alert line. 2. Health facilities with comprehensive EmOC. • Used to monitor both high and low risk labour

12. PROTOCOL FOR LABOUR MANAGEMENT WITH THE WHO PARTOGRAM

13. EXCLUSIONS Don’t complete the partogram in case of: • Prematurity (<34/40) • Cervical dilatation 9 -10 cm on admission • Elective CS • Emergency CS on admission

14. STARTING THE PARTOGRAM • Latent phase • Contractions at least 2 in 10, lasting ≥ 20 sec • Active phase • Contractions at least 1 in 10, lasting ≥ 20 sec • SRM but no contractions • When oxytocin is started or when labour commences • Inductions • At ARM ± oxytocin • When induction is medical start when labour commences (see 1 and 2) or membranes rapture.

15. DESIRED UTERINE CONTRACTIONS • The desired rates of uterine contractions in labour = 4 - 5 in 10 minute, each lasting 40-50 seconds. • It may be maintained at that rate throughout 2nd and 3rd stage of labour

16. TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE UP TO ACTION LINE

17. TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE • Vaginal examination may be carried out more frequently in advanced first stage 7+cm or if problems develop

18. MANAGEMENT OF LABOUR BETWEEN ALERT AND ACTION LINES • Known as Alert or Referral zone 1. Health facilities with Basic EmOC • Transfer the woman to hospital unless the cervix is almost fully dilated • ARM may be performed if membranes are still intact and first stage of labour is advanced and delivery is expected soon.

19. MANAGEMENT OF LABOUR BETWEEN ALERT AND ACTION LINES 2. Health Facility with Comprehensive EmOC • Perform ARM at vaginal examination • Continue routine monitoring • Repeat vaginal examination 4 hrs or earlier if delivery is expected sooner • Do not intervene or augment – unless complications develop

20. MANAGEMENT OF LABOUR AT OR BEYOND THE ACTION LINE • Full medical and obstetric assessment • Consider IV infusions/ catheterization/ analgesics (pethidine) • Options • Perform CS - if fetal distress or obstructed labour or operative vaginal delivery if in 2nd stage without severe fetal distress and/or obstructed. • Oxytoxin – if no contraindications • Supportive therapy only – if satisfactory progress is established and dilatation could be anticipated at 1cm/hr or faster.

21. FURTHER REVIEW - in cases continuing in labour • Vaginal exam after 2 hours, then in 2 more hours, then in 2 more hours • Failure to make satisfactory progress, measured as cervical dilatation of < 1cm/hr between these examinations, means delivery is indicated • Fetal heart while on oxytocin must be checked at least every ½ hour

22. INTERVENTION OF LABOUR Considerable factors for intervention of labour • Cervical dilatation and descent • Presentation, • Fetal condition e.g. fetal distress • Maternal condition • Strength and frequency of uterine contractions • Moulding/caput formation score

23. INTERVENTION OF LABOURcont • Consider all these factors, do not be guided only by the dilatation of the cervix in relation to the action line and by the descent of the fetal head, critical though these are. • Intervention needs to be earlier in a multip than in a prim. • Some partograms have two action lines one at 3 hours for multips and one at 4 hours for prims

24. ABNORMAL PARTOGRAPM Include the following • Prolonged latent phase • Protracted dilatation of cervix • Arrested dilatation of cervix • Protracted descent of the presenting part • Arrested descent of the presenting part • Prolonged second stage of labour

25. CAUSES OF ABNORMAL PARTOGRAPM Divided into 3 Ps • Passenger related • Refers to the fetus: Big baby, hydrocephaly, • Power related • Refers to the expulsive efforts of the uterus and mother: Poor uterine contractions etc • Passage related • Refers to the bony and soft tissue of the pelvis, vagina and perineum: Contracted pelvis - CPD

26. SPECIAL CASES ON THE PARTOGRAM • Breech • Twins • IUFD • Pre-eclampsia • Previous scar • Diabetes • Cardiac diseases NOTE: • Plot the labour on the partograph but specific WHO partogram may not apply • Such cases are managed individually

27. MANAGEMENT OF LABOUR IN SPECIAL CASES 1. BREECH • Exclude reasons for immediate CS • previous CS, contracted pelvis • Manage latent phase normally • CS may be indicated if the 8 hour latent phase “action line” is reached • In the active phase, dilatation slower than 1cm/hr is a worrying sign • Consider oxytocin if dilatation moves to the right of the alert line • Reaching the action line is normally the indication for CS

28. MANAGEMENT OF LABOUR IN SPECIAL CASES cont 2. Multiple pregnancy • Guidelines for breech apply i.e. prolonged latent phase or reaching the action line is indication for CS 3. Pre-eclampsia • Induction , augmentation and ARM may be indicted early i.e. in the latent phase before 8 hours or before the action line

29. MANAGEMENT OF LABOUR IN SPECIAL CASES cont 4. IUFD • Usually the WHO protocol can be followed • Only perform ARM in the active phase • When intervention is indicated as per WHO protocol– consider destructive delivery rather than CS

30. MANAGEMENT OF LABOUR IN SPECIAL CASES cont 5. Previous scar • 2 previous CS or classical CS → immediate CS • Otherwise use WHO protocol but do not use oxytocin • Reaching the action line usually an indication for CS

31. SUMMARY Proper use of partogram is associated with prevention of abnormalities of labour as associated complications and consequently reduction of both maternal and perinatal mortalities and morbidities