Partogram by Dr Uttara Gupta

Partogram is a useful tool for the assessment and management of labour. This presentation describes the method to plot partogram and means how to assess prolonged labour by using it.

1. PARTOGRAM Dr Uttara Gupta 1 st year PG Resident OBGY

2. Introduction The intrapartum period is a very dangerous and traumatic period – a time associated with a high mortality and morbidity for both mother and child. Hence, maternal and fetal monitoring are essential to pick up problems early and thus institute timely intervention.

3. A partograph is a composite graphical record of all the events of labour including maternal condition, fetal condition and progress of labour in relation to time, on a single sheet of paper . The central feature is the graph of cervical dilatation in cms against time. Can serve as a system to diagnose prolonged labour and fetal distress and can assist in making timely decisions on transfers (referrals) or interventions like Instrumental delivery or Immediate LSCS.

4. HISTORY E.A. Friedman was the first obstetrician to describe the progress of labour graphically in 1954. The progress was recorded in cms of dilatation per hour. The resulting graph was an S- shaped curve.

5. Friedman divided labour functionally into two parts- Latent phase Active phase- further subdivided into three parts:- - Acceleration phase - Phase of maximum slope (4 to 9 cm) - Deceleration phase (9 to 10 cm)

6. Philpott and Castle (1972) introduced concept of "ALERT" and "ACTION" lines to the graph to identify abnormal form of labour to suggest intervention. WHO gave a composite partograph in 1988 and later on modified partograph was introduced in 2000. The ‘Modified partograph ’ is used widely now.

7. WHO partograph 1988 Active phase commences at 3cms of dilation. Latent phase should not be > 8hrs. Rate of cervical dilatation should not be slower than 1cm/hr.

8. Changes in Modified WHO Partograph (2000) Latent phase is removed. Beginning of active phase is considered at 4 cms instead of 3 cms . Two squares in one hour instead of one square in one hour in 1988, i.e. one square equals to 1/2 hour in modified partography .

9. Why latent phase is removed Latent phase is difficult to differentiate from False labour pains, and is most often a "retrospective diagnosis ". R isks of "prolonged latent phase" in the presence of intact membranes and no other complications is almost minimal i.e.neonatal outcome is not compromised. Prolonged latent phase is a rare observation in hospital deliveries (>21 hrs in Primi and >14 hrs in Multi)

10. Latest Guidelines According to ACOG guidelines , March 2014 (Reaffirmed in 2019), active phase of labour starts from6 cms . From 4 to 6 cm, nulliparous and multiparous women dilate at almost the same rate, and more slowly than historically described. Beyond 6 cms Multiparous women dilate more rapidly.

11. NORMAL DURATION OF STAGES OF LABOUR STAGE PRIMI MULTI Stage 1 a) Latent Phase b) Active Phase 4-20 hrs 4-12 hrs 3-14 hrs 1.5-8 hrs Stage 2 30 mins – 3 hrs 10 mins - 2 hrs Stage 3 15 mins 15 mins Stage 4 2 hrs observation 2 hrs bservation

12. COMPONENTS Patient Identification : Name, age, Gravida , Para, IPD no, Time of rupture of membranes etc. Fetal record : FHR, Color of amniotic fluid, moulding. Progress of labour record : Cervical Dilatation, Descent of fetal head and uterine contraction. Maternal record : Pulse, BP, Temperature and urine examination, Drugs & IV Fluids, Oxytocin regime. Outcome

13. Starting a Partograph A partograph should be started only when a woman is in active phase of labour. Cervical dilatation must be 4 cms or more. If any mother comes first time at more than 4 cms dilatation ( eg . 6cm), it is plotted over the alert line, where the horizontal line corresponding to 6 cm dilatation crosses the alert line, assuming that the normal rate of cervical dilatation is 1 cm/hour. So that 2 hours before, the dilatation was 4 cms . This is known as Extrapolation .

14. 1 st part is patient particulars. Name, Gravida , Para, Hosp. No. Date and time of admission Ruptured membrane, Hours

15. Recording Fetal Heart Rate Recorded at top of Partograph . Recorded half hourly for 1 minute, preferably in left lateral position, immediately after peak of contraction. Normal FHR is between 120 to 160 bpm . Abnormal Heart rate should be heard every 15 mins for at least 1 minute. If three consecutive heart rate observations remain abnormal, action should be taken.

16. Fetal Heart Rate FHR Interpretation 110-160 NORMAL 100-109 Or 161-180 Borderline- Be alert >180 Fetal Tachycardia <100 Fetal Bradycardia & Fetal distress Fetal Tachycardia is the initial sign of fetal distess

17. STATUS OF MEMBRANES AND LIQUOR Recorded just below the FHR. Five types of observations are recorded- Membranes intact- write ‘I’ If membranes are ruptured- mention the color of Liquor. -Clear- ‘C’ - Meconium stained- ‘M’ -Blood stained- ‘B’ -Absent- ‘A’

18. MOULDING OF SKULL BONES Moulding is an important indication of how adequately the pelvis can accommodate the fetal head. Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion. -Separated bones, sutures felt easily ---- 0 -B ones just touching each other --- +1 - Overlapping bones (reducible) --- +2 - Severely overlappin g bone s ( nonr educibl e )--- +3

19. Fetal condition- Moulding Sagittal suture Metopic suture Coronal suture

20. DILATATION OF CERVIX Along the left side (vertical) numbers from 1 to 10 are present each square represents 1 cm dilatation, hence 10 cms mean full dilatation. Along the bottom of graph, there are numbers from 0 to 12, where each number represents 1 hour. Each hour is divided into 2 squares, where one square represents 1/2 an hour. Vaginal examination is done on admission and repeated 4 hourly in an otherwise normal case.

21. Dilatation of cervix is plotted as ‘X’. Descent of head is plotted as ‘O’. In about 90% Primigravida , cervix dilates at rate of 1cm/hr or faster in active phase. In precipitate labour rate can be 5cm/hour or more.

22. ALERT LINE Oblique line on the cervical d ilatation area, that goes from 4 to 10 cm of cervical dilatation. Represents the rate of cervical dilatation 1 cm per hour. Slowest acceptable ‘normal’ rate of cervical dilatation in active labour. If the curve moves to the right of the alert line , it indicates delay in labour.

23. ACTION LINE Oblique line in the Cervical Dilatation Area that runs parallel and four hours to the right of the Alert Line. If the cervical dilatation graph reaches or crosses the Action line, it indicates dangerously slow progress of labour. Complete assessment must be performed and decision must be made about the cause of the slow progress, and appropriate action taken.

24. L eft of or on the alert line Do not augment with oxytocin or intervene unless complications develop . ARM may be done at any time in the active phase (ARM is never done in Latent phase).

25. Between Alert and Action lines In a Health Centre: Transfer to hospital with facilities for augmentation of labour and Cesarean sectio n are available. ARM may be performed if membranes are still intact and observe labour for a short period before transfer . In Hospital: Perform ARM if membranes are intact and augment with Oxytocin continue routine observations .

26. At or Beyond Active Phase Action Line Full medical assessment Consider IV infusion/bladder catheterization/analgesia Options : Delivery by LSCS, if fetal distress or obstructed labour Supportive therapy (only if satisfactory progress is now established and dilatation could be anticipated at 1cm/hr or faster)

27. DESCENT OF FETAL HEAD Descent may not take place until cervix has reached 7 cm dilatation. Plotted from 5 to 0, by symbol ‘O’. Measured abdominally in ‘Fifth’s above the pelvic brim’ method (Crichton method). More reliable than vaginal assessment. When 2/5 or less of fetal head is felt above the level of symphysis pubis, this means that the head is engaged.

28. By vaginal examination, the lowest part of vertex has passed or is at the level of ischial spines in absence of caput, is said to be engaged head.

29. UTERINE CONTRACTIONS Progressive uterine contractions are essential for progress of labour. Half hourly contractions are observed per abdominally in active phase (one hourly in Latent phase and every 15mins in second stage). Frequency and duration of contractions are monitored and plotted on partogram . One square represents one contraction, contractions per 10 mins is written on the left side. Normal contractions – 3 cont/45 secs /10 mins in first stage -3 to 5cont/ 50-55secs/10mins in second stage

30. DRUGS AND IV FLUIDS Recorded at the foot of the Partogram . Oxytocin IV Fluids Other Drugs : Drotin , Epidosin , Tramadol , Pethidine , Promethazine

31. Oxytocin dose calculation One ampoule of oxytocin contains 5 Units of drug. Dissolve in 500 ml NS. Conc. is 10 Unit per Litre (10 U/L ). Half ampoule is dissolved in 500 ml NS Conc entration i s 5 Unit per Litre (5 U/L ) Oxytocin is started as a low dose in normal saline and rate is doubled every 30 mins . 4 drops/min = 2.5 milliunits /min Maximum dose is 40 milliunits /minutes (60drops/minute)

32. MATERNAL CONDITION Recorded at the bottom. Pulse- half hourly, marked by a dot. BP- 4 hourly or more frequently, if required. Temperature- 4 hourly Urine- Volume, protein and ketone . Patient is encouraged to pass urine 2 to 4 hourly.

33. How should the labour progress be monitored in second stage of labour? The condition of mother and the fetus should be monitored more frequently . The cervix is fully dilated and no further recordings of cervical dilatation are required . it is important to monitor other information e.g. frequency and strength of uterine contractions, descent of the fetal head, fetal heart rate, colour of amniotic fluid, medications administered, etc.

34. N ot restricted to vertex presentations. It can be used in all situations where vaginal birth can be expected. For example , i n breech presentation , Face presentation, descent of the fetal head and moulding are not assessed . Not used in transverse lie and brow presentation . Can the partograph be used only in vertex presentation?

35. Paperless Partogram - Dr. Aloke Debdas in Jamshedhpur developed this simple tool in which estimated time of delivery (ETD) is calculated in active labour, considering 1 cm/hr dilataion , when action is taken if there is delay of 4 hours after the time of delivery. Digital partogram - Electronic implementation of a standard paper based partogram that can work on a tablet or PC. It has alarm system which can remind to enter labour vitals in case, the standard protocol is not followed.

36. ADVANTAGES OF USING PARTOGRAM Specific information about cervical dilatation, descent of head and fetal distress can be obtained on one sheet of paper. Early prediction of deviation from normal labour and proper intervention could be done in time, like instrumental delivery at the end of second stage or LSCS. Recognizes prolonged labour and fetal distress. Simplifies transfer of patients to the first referral unit. Facilitates handover and responsibility during change of shift.

37. Documented evidence for Medico Legal purpose. Educational value for all grades of staff. Reduces rate of un-necessary LSCS. Inexpensive tool to monitor labour. Less chances of neonatal complications as it records the color of liquor and FHS.

38. DISADVANTAGES OF PARTOGRAM Does not help to identify risk factors which are present prior to the labour. Does not predict the duration of labour before admission. To minimize error, it needs to be maintained by the same individual. Assumes that all women progress at same rate – May influence intervention rate.

39. ABNORMAL PARTOGRAM Precipitate labour- maximum dilatation of cervix is 5cm/hr , it is due to hypertonic uterine inertia. Prolonged active phase- two types a) Primary arrest of cervical dilatation/ Cervical dystonia - -Slow dilatation less than 1 cm/hr, for minimum four hours. -Graph crossing the alert line - Reasons- Hypotonic uterine inertia, Fetal macrosomia , CPD, OP position

40. b) Secondary Arrest of Cervical dilatation- -Slow dilatation after 6-7 cm dilatation - Reason - CPD, Large size baby -In beginning normal dilatation recorded on partogram , but later on horizontal line . 3 . Abnormality of descent of head/ Failure of descent- -Diagnosed when normal descent then secondary arrest after 10 cm cervix or in second stage of labour. Reasons- CPD, Fetal macrosomia LSCS is indicated

41. Ina d equ at e u t erin e co n t r ac t i o ns c o r r e c t e d with oxytocin

42. C. simplified partograph by WHO This version simplifies the partograph for use at primary level. Colour codes (green, yellow and red) help the user to identify normal labour (green) and distinguish it from slow progress (yellow: watch out ; red: danger ).