2. partograph & Episiotomy

Partograph is composite graphical record of key data (maternal & fetal) during labour, entered against time on a single sheet of paper.
A surgical planned incision on the perineum and the posterior vaginal wall during the second stage of labour is called episiotomy (perineotomy).

1. Partograph & Episiotomy By David V. Daryapurkar

2. P ARTOGRAPH Partograph is a composite graphical record of key data (maternal and fetal) during labor, entered against time on a single sheet of paper In cervicograph (Philpott & Caste — 1972), the alert line starts at 4 cm (WHO) of cervical dilatation and ends at 10 cm dilatation (at the rate of 1 cm/ hr ). The action line is drawn 4 hours to the right and parallel to the alert line. In a normal labor , the cervicograph (cervical dilatation) should be either on the alert line or to the left of it .

3. The components of a partograph are: (a) Patient identification; (b) Time — recorded at hourly interval. Zero time for spontaneous labor is the time of admission in the labor ward and for induced labor is the time of induction; (c) Fetal heart rate — recorded at every 30 minutes; (d) State of membranes and color of liquor : to mark ‘I’ for intact membranes, ‘C’ for clear and ‘M’ for meconium stained liquor; (e) Cervical dilatation and descent of the head.

4. The components of a partograph are: cont … (f) Uterine contractions — the squares in the vertical columns are shaded according to duration and intensity. (g) Drugs and fluids; (h) Blood pressure (recorded in vertical line) at every 2 hours and pulse at every 30 minutes; ( i ) Oxytocin — concentration in the upper box and dose (m IU/min) in the lower box; (j) Urine analysis; (k) Temperature record.

5. The components of a partograph are: cont … (l) MOULDING: ‘0’: Sutures felt easily. (-): Absence of moulding. (+): Bones are touching each other. (++): Bones are overlapping.

6. Advantages of a partograph: ( i ) A single sheet of paper can provide details of necessary information at a glance; (ii) No need to record labor events repeatedly; (iii) It can predict deviation from normal progress of labor early. So, appropriate steps could be taken in time (iv) It facilitates handover procedure; (v) Introduction of partograph in the management of labor (WHO 1994) has reduced the incidence of prolonged labor and cesarean section rate. There is improvement in maternal morbidity, perinatal morbidity and mortality.

7. PHYSICAL PROPERTIES: The active phase of labor commences at 4 cm cervical dilatation. The latent phase should last no longer than 8 hours. During the active labor, the rate of cervical dilatation should not be lesser than 1cm/hour. A 4 hourly vaginal examination is recommended.

8. PURPOSES: To record the clinical observations accurately. To identify the difference between latent and active phase of labor. To interpret the recorded Partograph and to identify any deviation from normal. To monitor the progress of labor and to recognize the need of action at the appropriate time for timely referral. To monitor the well-being of mother as she goes through labor.

9. GRAPHIC ANALYSIS OF LABOR: CERVICAL DILATATION: The examination is plotted with the zero time on the graph and done every 4 hourly. The points of each dilatation is joined by a line. It is divided into 2 phases: Latent phase : From the onset till the dilatation of about 4cm and lasts for 8-10 hours. Active phase : (4cm to 10 cm). Dilatation progresses at a rate of 1cm/ hr (primigravida) and 1.5cm/ hr (multigravida). Alert line : Drawn from 4cm-10cm and represents rate of dilatation. If the line is marked for the patient moves to the right of alert line, it indicates slow dilatation and thus delay in the progress of labor. Action line: It is drawn 4 hours to the right of the alert line. If the cervical dilatation reaches this line, it indicates delay and employs critical assessment and appropriate interventions to be taken.

10. GRAPHIC ANALYSIS OF LABOR: STATION OF HEAD: It is identified by vaginal examination and marked at the right side of the graph. TIME: It is recorded from the time of admission as zero time. In case of induction of labor, the starting time of induction is recorded as zero time and is recorded at hourly intervals. UTERINE CONTRACTIONS: Recorded at every 10 minutes interval. Oxytocin, drugs & I.V fluids: It is recorded in the space provided. MATERNAL CONDITION: B.P, PULSE & TEMPERATURE: Bp is recorded every 4 hourly; pulse every 30 minutes and temperature every 2 hourly. URINE: Check for acetone and protein.

11. Partograph (modified WHO) representing graphically the important observations in labor. The cervical dilatation and descent of head are shown in relation to alert and action lines.

12. PARTOGRAPH

13. EPISIOTOMY DEFINITION: A surgically planned incision on the perineum and the posterior vaginal wall during the second stage of labor is called episiotomy ( perineotomy ) . It is in fact an inflicted second-degree perineal injury. It is the most common obstetric operation performed. OBJECTIVES  To enlarge the vaginal introitus so as to facilitate easy and safe delivery of the fetus: spontaneous or manipulative.  To minimize overstretching and rupture of the perineal muscles and fascia; to reduce the stress and strain on the fetal head.

14. INDICATIONS: Episiotomy is recommended in selective cases rather than as a routine . A constant care during the second stage reduces the incidence of episiotomy and perineal trauma.  In elastic (rigid) perineum: Causing arrest or delay in descent of the presenting part as in elderly primigravidae.  Anticipating perineal tear: (a) Big baby (b) face to pubis delivery (c) breech delivery and (d) shoulder dystocia.  Operative delivery: Forceps delivery, ventouse delivery.  Previous perineal surgery: Pelvic floor repair, perineal reconstructive surgery. Common indications are: (1) Threatened perineal injury in primigravidae (2) rigid perineum and (3) forceps, breech, occipitoposterior or face delivery.

15. Timing of the episiotomy: The timing of performing the episiotomy requires judgment. If done early, the blood loss will be more. If done late, it fails to prevent the invisible lacerations of the perineal body and thereby fails to protect the pelvic floor – the very purpose of the episiotomy is thus defeated. Bulging thinned perineum during contraction just prior to crowning (when 3–4 cm of head is visible) is the ideal time . During forceps delivery, it is made after the application of blades.

16. ADVANTAGES  Maternal: It is controversial whether routine episiotomy has got any major benefits. The suggested benefits are: (a) a clear and controlled incision is easy to repair and heals better than a lacerated wound that might occur otherwise (b) reduction in the duration of second stage and (c) reduction of trauma to the pelvic floor muscles—that reduces the incidence of prolapse and perhaps urinary incontinence.  Fetal: It minimizes intracranial injuries, especially in premature babies or after-coming head of breech.

17. TYPES • Mediolateral • Median Mediolateral: The incision is made downwards and outwards from the midpoint of the fourchette either to the right or to the left. It is directed diagonally in a straight line which runs about 2.5 cm away from the anus (midpoint between anus and ischial tuberosity). Median: The incision commences from the center of the fourchette and extends posteriorly along the midline for about 2.5 cm.

18. TYPES • Lateral • ‘J’ shaped Lateral: The incision starts from about 1 cm away from the center of the fourchette and extends laterally. It has got many drawbacks including chance of injury to the Bartholin’s duct. It is totally condemned. ‘J’ shaped: The incision begins in the center of the fourchette and is directed posteriorly along the midline for about 1.5 cm and then directed downwards and outwards along 5 or 7 O’clock position to avoid the anal sphincter. Apposition is not perfect and the repaired wound tends to be puckered. This is also not done widely.

19. Table:- Relative Merits and Demerits of Median and Mediolateral Episiotomy

20. Diagrammatic representation of the structures to be cut in different types of episiotomy

21. Repair Timing of repair : the repair is done soon after expulsion of placenta. If repair is done prior to that, disruption of the wound is inevitable, if subsequent manual removal or exploration of the genital tract is needed. Oozing during this period should be controlled by pressure with a sterile gauze swab and bleeding by the artery forceps. Early repair prevents sepsis and eliminates the patient’s prolonged apprehension of “stitches”. Preliminaries : The patient is placed in lithotomy position. A good light source from behind is needed. The perineum including the wound area is cleansed with antiseptic solution. Blood clots are removed from the vagina and the wound area. The patient is draped properly and repair should be done under strict aseptic precautions. If the repair field is obscured by oozing of blood from above, a vaginal pack may be inserted and is placed high up. Do not forget to remove the pack after the repair is completed .

22. Steps of repair of episiotomy— (A) Wound on inspection; (B) Repair of vaginal mucosa; (C) Reapir of perineal muscles by interrupted sutures; (D) Apposition of the skin margins; (E) Repaired wound on inspection A B C D E

23. The repair is to be done in the following order: (1) Vaginal mucosa and submucosal tissues (2) perineal muscles and (3) skin and subcutaneous tissues. The vaginal mucosa is sutured first . The first suture is placed at or just above the apex of the tear . Thereafter, the vaginal walls are apposed by interrupted sutures with polyglycolic acid suture ( Dexon ) or No. “0” chromic catgut, from above downwards till the fourchette is reached. The suture should include the deep tissues to obliterate the dead space. A continuous suture may cause puckering and shortening of the posterior vaginal wall. Care should be taken not to injure the rectum. Rest of the procedure is discussed before

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