Maximizing Labour Management Efficiency with the Partogram Tool

1. Partogram and Obstructed LabourH. Gee MD, FRCOGConsultant Obstetrician

2. When is a Woman in Labour?

3. Good Management ofLabour

4. First StagePatternsof Aberrance

5. Patterns of Aberrance • Prolonged Latent Phase • Slow cervical dilatation before Active Phase established • 20 hrsNullips & 14 hrsMultips • Primary Dysfunctional Labour • Progress< 1 cm/hr before Active Phase slope established • Incidence: Nullips 26%, Multips 8% • Secondary Arrest • Cessation after normal active phase dilatation • Incidence: Nullips 6%, Multips 2%

6. PARTOGRAM- EAST AFRICA’S GIFT TO THE WORLD • Invented in Africa 1960’s • Identify delay • Identify increasing risk • To determine place of delivery • No comparative or controlled trials • Common sense value recognised

7. 10 8 6 4 2 ActionLine Alert Line Cervical Dilatation (cms,) 0 2 4 6 8 10 Time (hrs.) Active Phase Cervicograms- Philpott & Castle

8. WHO Partograph Study • Reduced incidence of prolonged labour (8.3% vs 4.5%) • Decreased need for augmentation (32% vs 13%) • Increased spont vag del (74% vs 78%) • Decreased caesarean section (9.8% vs 6.8%) * Lancet 1994 343;1399-1404 (Nullips) * not Statistically Sig

9. Why not done?Result from Malawi audit

10. Partograph assessment by progress of labour and augmentation, by type of facilityResults from Malawi audit

11. Second Stage • Descent • Rotation • Duration • Passive • Active(Pushing)

12. Current situation • Midwife tells you CS needed • Problems • Is she right? • Do you understand the problem & implications. • Are there alternatives? • e.g. forceps/vacuum in second stage

13. New situation • You are team leader because of this course • When called • You assess patient • Power/passages /passenger • You improve care by whole team

14. Parity & Obstruction • Nulliparous • Inertia • Multiparous • Uterine Rupture

15. COMPONENTS OF LABOUR • The powers • Uterine contractions • The passages • bony pelvis, and soft tissues • The passenger • fetus

16. Powers • Essential for good progress • Cervical Dilatation • Flexion • Rotation • Assessed by Palpation • Frequency 3-5 in 10 min. • Augmented by Oxytocin & Amniotomy

17. The Passages • Bony pelvis • Absolute cephalo-pelvic disproportion • Kyphosis, Scoliosis, poliomyelitis, maternal dwarfism, ricketts, pelvic fracture. • Soft tissue • fibroids, ovarian tumour, pelvic kidney, fat, cervical stenosis, cervical cancer, vaginal\vulval atresia, vaginal septum.

18. The Passages Disproportion • Head Not Engaged • > 4/5 Palpable abdominally • VE: high head, caput+++, moulding+++ • CS essential • PPH • Risk increased in Prolonged/Obstructed labour

19. The Passenger-1 • Large Fetus • Idiopathic • Increasing Parity • Pathologic macrosomia, • diabetes • Fetal abnormalities • hydrocephalus • conjoined twins • hydropsfetalis

20. The Passenger-2 • Malposition • Occipito-Posterior • Mento-Posterior • Malpresentation • compound presentations • shoulder • brow • face

21. Signs of Obstruction • Maternal • Tachycardia • Pyrexia • Ketosis • Dehydration • Fetal • Fetal heart rate abnormalities

22. Treatment • General • Re-hydration • Anti-biotics (if infection suspected) • Specific • According to diagnosis • Caesarean section

23. Caesarean Section in Obstruction • Cesarean Section Problems • Impacted head – dis-impact before start • PPH • IV sytno/ergometrine/misoprostol ready • Bladder Injury • Leave catheter in for 10 days if blood stained • Infection • IV antibiotics

24. Post delivery • Reflective practise- team leader • Critical incident review • WHY Poor Outcome? • NO TRAINING • NO EQUIPTMENT • POOR COMMUNICATION • MATERNAL HEALTH VERY POOR

25. Improve PartogramUse • 4 hourly ward rounds/teaching • Critical incident review • What was wrong? • Audit • Change • Re-audit