MONITORING THE PROGRESS OF LABOUR.pptx

Presentation on monitoring of labour using a partograph in Tanzania

1. MONITORING THE PROGRESS OF LABOUR Beata Mushema MD, MSc July 2023

2. SESSION OBJECTIVES By the end of this session, you should be able to: Describe the uses and value of partograph Describe the main parts of a partograph Describe the indicators in a partograph that show good progress of labour , and signs of fetal and maternal wellbeing Plot and interpret a partograph (composite and modified)

3. INTRODUCTION More than one third of maternal deaths, half of stillbirths and a quarter of neonatal deaths result from complications during labour and childbirth. Monitoring of labour and childbirth, and early identification and treatment of complications are critical for preventing adverse birth outcomes.

4. PARTOGRAPH The partograph is a graphical presentation of the progress of labour , and of fetal and maternal condition during labour . It is the best tool to help you detect whether labour is progressing normally or abnormally, and to warn you as soon as possible if there are signs of fetal distress or if the mother’s vital signs deviate from the normal range.

5. EVOLUTION OF THE PARTOGRAPH

6. EVOLUTION OF THE PARTOGRAPH (FRIEDMAN) Emanuel Friedman established criteria for the normal progress of labor in the 1950s. He conducted his studies defining the spectrum of normal labor by evaluating the course of labor of different women. He observed that normal labor should progress at a rate of at least 1 cm cervical dilatation per hour, starting at 3 to 4 cm of dilatation.

7. EVOLUTION OF THE PARTOGRAPH (FRIEDMAN) Friedman divided labour functionally into two parts: The (early)  latent phase  extends over 8-10 hours and up to about 3 cm dilation. This was followed by an  active phase , characterized by acceleration from about 3-10 cm at the end of which deceleration occurred. This work has been the foundation on which others have built.

8. EVOLUTION OF THE PARTOGRAPH (PHILPOTT AND CASTLE) In the 1960’s Philpott proposed the use of a graph to represent the progress of labour with the primary aim to identify abnormal progress. Philpott and Castle developed the first partograph, by utilizing Friedman's cervicograph , and adding the relationship of the presenting part to maternal pelvis on their graph as a means to assess labour progress. Philpott devised a key for assessing and documenting uterine contractions over a 10 - minute period. This was also added to the partograph format to aid in the assessment of labour progress.

9. EVOLUTION OF THE PARTOGRAPH (PHILPOTT AND CASTLE) As well as assessing the progress of labour, Philpott added an assessment of foetal condition by devising a system of foetal heart rate grading, and a scale for assessing the presence of caput and moulding as a means of detecting degrees of cephalopelvic disproportion.

10. EVOLUTION OF THE PARTOGRAPH (PHILPOTT AND CASTLE) In the 1970’s Philpott and Castle researched their partograph in the management of labour in primigravid women in Rhodesia (Zimbabwe). From this research, and their aims to identify abnormal labour and reduce mortality rates, they added action and alert lines and other intrapartum details to their cervicographs to complete the partograph. Alert and action lines were added to identify "at risk" labouring women who would need transfer from rural centers to specialized units for active management of their labour.

11. EVOLUTION OF THE PARTOGRAPH (WHO) In 1987 the Safe Motherhood conference was held in Nairobi, and as a part of the Safe Motherhood Initiative the WHO revised, approved, and promoted the universal use of the partograph with view to reducing maternal and fetal mortality.

12. EVOLUTION OF THE PARTOGRAPH (WHO COMPOSITE PARTOGRAPH) The first WHO partograph or ‘Composite partograph’, covers a latent phase of labour of up to 8 hours and an active phase beginning when the cervical dilatation reaches 3 cm. The active phase is depicted with an alert line and an action line, drawn 4 hours apart on the partograph. 

13. EVOLUTION OF THE PARTOGRAPH (WHO MODIFIED PARTOGRAPH) Since a prolonged latent phase is relatively infrequent and not usually associated with poor perinatal outcome, the usefulness of recording the latent phase of labour in the partograph has been questioned. Moreover, differentiating the latent phase from false labour is often difficult. To alleviate these disadvantages, a modified WHO partograph was introduced and incorporated removal of the latent phase and defined the beginning of the active phase at 4 cm cervical dilatation instead of 3 cm.

14. Modified WHO partograph

15. WHO LABOUR CARE GUIDE (2020) User-friendly design New start of active phase Supportive care (birthing position, companion, pain relief, oral fluids) Shared decision making Alert thresholds

16. WHEN TO START A PARTOGRAPH In current practice, a partograph is started when a women is in active phase of the first stage of labour (starting at 4cm). It should be used during the process of labour and not plotted after delivery. Personal information including name, gravida, para, registration/hospital number, date and time of admission, time of ruptured membranes is written at the top of the graph.

17. MAIN COMPONENTS OF THE PARTOGRAPH

18. FOETAL CONDITION

19. Foetal Heart Rate This is recorded half-hourly to monitor the condition of the fetus. Plotted with a dot . Normal range 120-160bpm (WHO)

20. Liquor Amniotic fluid is observed and recorded at each vaginal examination as follows: I – the membranes intact C – clear amniotic fluid В – blood-stained amniotic fluid M – meconium -stained amniotic fluid A – absent amniotic fluid

21. Moulding The bones of the fetal head can move closer together or overlap to help the head fit through the pelvis. Parietal bones overlap occipital and frontal bones. Moulding is assessed and recorded at each vaginal examination as follows:

22. Degrees of Moulding If parietal bones are separated and the sutures can be felt easily: record as “0". If parietal bones are just touching each other: record as “+” or “+1) If parietal bones are overlapped but easily reduced with digital pressure: record as “++” or “+2) If parietal bones have overlapped and are irreducible. reduced: record as “+++” or “+3)

23. Degrees of Moulding

24. Moulding Up to 2+ moulding may be normal in the later stages of labour. Severe moulding (3+) is a sign of obstruction.

25. PROGRESS OF LABOUR

26. Cervical dilatation This is the most important observation to monitor progress of labour. Cervical dilatation is assessed at every vaginal examination (every 4 hours) Cervical dilatation is plotted with: X

27. Descent Descent assessed by abdominal palpation refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis. It is assessed every 4 hours. Descent is plotted with: O

28. Contractions Less than 20 seconds 20-40 seconds More than 40 seconds Contractions are recorded every 30 minutes; palpate the number of contractions in 10 minutes and their duration in seconds.

29. MATERNAL CONDITION

30. Maternal condition Oxytocin, drugs and intravenous fluids if given are recorded in the spaces provided. Pulse (plotted with dots on the partograph) should be taken every 30 minutes Blood pressure (reported by a line between systolic and diastolic pressure values) and temperature – every 4 hours (or more often, if necessary) Record amount of urine passed every 2-4 hours The urine should be tested for protein and acetone, if indicated

31. PARTOGRAPH EXERCISES Plot and interpret the partographs of the following women

32. CASE 1 Maria R. G4P3, admitted on 16/02/2023 at 22:00hrs (Hospital number 345836) Fetal heart rate - 136 beats / min Amniotic fluid – intact No moulding Cervical dilatation – 4 cm Head descent - 4/5 3 contractions in 10 min each less than 20 seconds Blood pressure – 120/70mmHg Pulse – 70 beats /min Temperature – 36.4 ºC Urine – 90 ml

33. Fetal heart rate 22:30 - 140 beats / min, 23:00 - 150 beats / min, 23:30 - 140 beats / min, 00:00 - 130 beats / min, 00:30 - 140 beats / min, 01:00 - 146 beats / min, 01:30 - 132 beats / min, CASE 1

34. Uterine contractions 22:30 - 3 contractions lasting less than 20 seconds, 23:00 - 3 contractions lasting 30 seconds, 23:30 - 3 contractions lasting 35 seconds, 00:00 - 3 contractions lasting 40 seconds, 00:30 - 4 contractions lasting more than 40 seconds, 01:00 - 4 contractions lasting more than 40 seconds 01:30 - 4 contractions lasting more than 40 seconds CASE 1

35. Maternal Pulse 22:30 - 80 beats / min, 23:00 - 80 beats / min, 23:30 - 90 beats / min, 00:00 - 90 beats / min, 00:30 - 90 beats / min, 01:00 - 80 beats / min, 01:30 - 80 beats / min, CASE 1

36. CASE 1 At 02:00 Fetal heart rate - 140 beats / min Amniotic fluid – clear Fetal bones slightly overlap but are reducible Cervical dilatation – 8 cm Head descent - 2/5 4 contractions in 10 mins lasting more than 40 seconds Blood pressure – 125/80mmHg Pulse – 82 beats /min Temperature – 36.7 ºC Urine – 140 ml

37. At 02:50 she delivered by SVD a live male, BWT 3600g CASE 1

38. Helena M. G3P2 02/03/2023 at 09:00 (Hospital number 986843) Fetal heart rate – 132 beats /min Amniotic fluid – intact Head moulding – no Cervical dilatation – 2 cm Head descent – 5/5 Contractions in 10 min – 2 contractions each lasts 25 seconds Blood pressure – 140/80 Pulse – 80 beats /min Temperature – 36.4 ºC Urine – 120 ml CASE 2

39. CASE 2 At 13:00 Fetal heart rate – 140 beats /min Amniotic fluid – clear Head moulding – no Cervical dilatation – 5 cm Head descent – 4/5 Contractions in 10 min – 3 contractions each lasts 35 seconds Blood pressure – 135/80 Pulse – 82 beats /min Temperature – 36.4 ºC Urine – 150 ml

40. CASE 2 Fetal heart rate 13:30 - 140 beats / min, 14:00 - 150 beats / min, 14:30 - 130 beats / min, 15:00 - 130 beats / min, 15:30 - 140 beats / min,

41. CASE 2 Contractions per 10 minutes 13:30 - 3 contractions each lasts 35 seconds, 14:00 - 3 contractions each lasts 40 seconds, 14:30 - 3 contractions each lasts 50 seconds, 15:00 - 4 contractions each lasts 55 seconds, 15:30 - 4 contractions each lasts 55 seconds,

42. CASE 2 Maternal Pulse 13:30 - 80 beats / min, 14:00 - 80 beats / min, 14:30 - 90 beats / min, 15:00 - 90 beats / min, 15:30 - 90 beats / min,

43. CASE 2 At 16:00 Fetal heart rate – 146 beats /min Amniotic fluid – clear Head moulding – the bones slightly overlap but are reducible Cervical dilatation – 9 cm Head descent – 1/5 Contractions in 10 min – 4 contractions each lasts 55 seconds Blood pressure – 140/80 Pulse – 88 beats /min

44. CASE 2 At 1645hrs she spontaneously delivered a live female with birth weight of 3800g

45. CASE 3 Elena Richard a 26-year-old pregnant woman at 38 weeks and 2 days gestation was admitted to the antenatal ward yesterday at 0400hrs, presenting with labour-like pains. This is her second pregnancy; her last child was delivered 3 years ago with a birth weight of 2.8kg and is alive. Her hospital number is 5657652. The following are her examination findings during admission

46. CASE 3 On admission: Fetal heart rate – 130 beats /min Amniotic fluid – clear Head moulding – no Cervical dilatation – 2 cm Head descent – 4/5 Contractions in 10 min – 2 contractions each lasts 20 seconds Blood pressure – 110/70mmHg Pulse – 68 beats /min Temperature – 37.5 ºC

47. CASE 3 At 0600hrs Fetal heart rate – 136 beats /min Amniotic fluid – clear Head moulding – no Cervical dilatation – 4 cm Head descent – 4/5 Contractions in 10 min – 3 contractions each lasts 40 seconds Blood pressure – 115/75mmHg Pulse – 70 beats /min Temperature – 36.7 ºC Urine- 120ml; NEG for Protein and Acetone

48. CASE 3 Fetal heart rate 0630hrs - 136 beats / min, 0700hrs - 138 beats / min, 0730hrs - 150 beats / min, 0800hrs- 150 beats / min, 0830hrs - 140 beats / min, 0900hrs – 130 beats / min, 0930hrs - 140 beats / min,

49. CASE 3 Uterine contractions 0630hrs - 3 in 10 mins; lasting 40 seconds 0700hrs - 3 in 10 mins; lasting 40 seconds, 0730hrs - 3 in 10 mins; lasting 40 seconds, 0800hrs- 3 in 10 mins; lasting 45 seconds, 0830hrs - 3 in 10 mins; lasting 45 seconds, 0900hrs – 4 in 10 mins; lasting 45 seconds, 0930hrs - 4 in 10 mins; lasting 45 seconds,

50. CASE 3 Maternal Pulse 0630hrs - 80 beats / min, 0700hrs – 80 beats / min, 0730hrs - 90 beats / min, 0800hrs- 90 beats / min, 0830hrs - 90 beats / min, 0900hrs – 80 beats / min, 0930hrs - 80 beats / min,

51. CASE 3 At 1000hrs Fetal heart rate – 140 beats /min Amniotic fluid – clear Head moulding – Parietal b ones are just touching each other Cervical dilatation – 6 cm Head descent – 3/5 Contractions in 10 min – 4 in 10 mins; lasting 50 seconds Blood pressure – 115/80mmHg Pulse – 85 beats /min Temperature – 36.6 ºC Urine- 100ml; NEG for Protein and Acetone

52. CASE 3 Fetal heart rate 1030hrs - 130 beats / min, 1100hrs - 140 beats / min, 1130hrs - 120 beats / min,

53. CASE 3 Uterine contractions 1030hrs - 4 in 10 mins; lasting 45 seconds, 1100hrs - 4 in 10 mins; lasting 55 seconds, 1130hrs - 4 in 10 mins; lasting 55 seconds,

54. CASE 3 Maternal Pulse 1030hrs - 80 beats / min, 1100hrs - 90 beats / min, 1130hrs - 100 beats / min,

55. CASE 3 At 1200hrs Fetal heart rate – 100 beats /min Amniotic fluid – meconium-stained Head moulding – Bones overlap and are not reducible Cervical dilatation – 6 cm Head descent – 3/5 Contractions in 10 min – 4 in 10 mins; lasting 55 seconds Blood pressure – 140/90mmHg Pulse – 100 beats /min Temperature – 36.7 ºC Urine- 100ml; NEG for Protein and Acetone

56. CASE 3 At 1225, she delivered by emergency caesarean section, a live female baby with a birth weight of 4500g and Apgar score 7-8.

57. REFERENCES Emanuel A. Friedman. Graphic Analysis of Labor. ResearchGate. January 6, 2011. Available at:  https://www.researchgate.net/publication/229994697_Graphic_Analysis_of_Labor R. H. Philpott, W. Castle. CERVICOGRAPHS IN THE MANAGEMENT OF LABOUR IN PRIMIGRAVIDAE. Published in July 1972. Available at:  https://www.semanticscholar.org/paper/CERVICOGRAPHS-IN-THE-MANAGEMENT-OF-LABOUR-IN-Philpott-Castle/de7d90cdea0c15410e55fae44f48815c1db0f6a1 WHO Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice – 3rd ed; 2015 WHO recommendations: intrapartum care for a positive childbirth experience. Geneva: World Health Organization; 2018 WHO labour care guide: user’s manual. Geneva: World Health Organization; 2020.

58. Thank you! Mobile: [phone] Email: [email protected] Office: Level 6, Room 614