Partograph

It is a composite graphical recording of cervical dilatation and descent of head against duration of labour in hours.

It also gives information about fetal and maternal condition that are all recorded on single sheet of paper.

1. Partograph Shrooti Shah Lecturer National Medical College Nursing Campus

2. Definition It is a composite graphical recording of cervical dilatation and descent of head against duration of labour in hours. It also gives information about fetal and maternal condition that are all recorded on single sheet of paper.

3. History E.A. freidman in 1954 provide a foundation basis for development of partograph on the basis of observation of large number of woman in labour . After that, the composite picture of labour was reported by philpott in 1972, who combined details of progress of labour together with information about fetal and maternal conditions.

4. Advantage of using Partograph A single sheet of paper can provide details of necessary information at a glance. No need to record labour events repeatedly Gives clear picture of normality and abnormality in labour . It can predict deviation from duration of labour . So appropriate steps could be taken in time.

5. Advantage of using Partograph… It facilitates handover procedure of staffs. Save working time of staff against writing labour notes in long hand. Educational value for all staff.

6. Principles of plotting partograph The active phase of labour commence at 4 cm cervical dilatation. The latent phase of labour should not last longer than 8 hours. During active labour , the rate of cervical dilatation should not be slower than 1cm/hours. A lag time at 4 hours between a slowing of labour and the need for intervention is unlikely to compromises the fetus or the woman and avoid unnecessary intervention

7. Method of recording partograph Patient information: Fill out name, gravida , para , hospital number, date and time of admission and time of ruptured membranes.

8. Method of recording partograph Fetal heart rate: The rate of the fetal heart rate indicates the state of the fetus inside the uterus. Record every half hour.

9. Method of recording partograph Amniotic fluid : Record the colour of amniotic fluid at every vaginal examination: • I: membranes intact; • C: membranes ruptured, clear fluid; • M: meconium -stained fluid; • B: blood-stained fluid.

10. Moulding Moulding is a state of reduction or loss of space between skull bones. Presence of increased moulding of the head high in the pelvis indicates CPD. Recording of degree of moulding 0: Bones are separated and sutures can be felt easily 1: sutures apposed 2: sutures overlapped but reducible 3: sutures overlapped and not reducible

11. Cervical dilatation Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm. This graph consists of homogenous squares, ten square vertically, each square indicate one centimeter of cervical dilatation.

12. Cervical dilatation

13. Cervical dilatation The cross (X) in the graph are joined by a continuous line begin plotting on the partograph at 4 cm. The climbing tendency of this line normally lies on the left of the middle of the graph. Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour. Action line: Parallel and 4 hours to the right of the alert line

14. Descent of the head This is assessed by abdominal examination before doing vaginal examination. Refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis. Recorded as a circle (O) at every vaginal examination.

15. Descent of the head

16. Hours: Refers to the time elapsed since onset of active phase of labour . Time: Record actual time.

17. Uterine contractions Uterine contractions are recorded graphically on the partograph according to their strength and frequency. Observation of contraction is made half hourly in the active phase. Palpate the number of contractions in 10 minutes and their duration in seconds

18. Uterine contraction

19. Uterine contraction

20. Oxytocin drip This consists of two lines, one for the record of unit of oxytocin per liter of intravenous fluid and other one is for drop of fluid per minute. The recording can be made at the interval of 30 minutes as the uterine contraction

21. Drugs and other intravenous fluids Record any additional drug given and are recorded at the particular point of time. This includes sedatives, antibiotics, IV fluids etc. The name of the drugs and doses given should be written clearly in the long box.

22. Maternal condition Pulse: Record every 30 minutes and mark with a dot ( . ). Blood pressure: Record every 4 hours and mark with arrows. Temperature: Record every 2 hours.

23. Urine analysis During the course of labour , the examination of urine is important. In case of maternal distress the volume of urine may decrease and it may contain ketone bodies.

24. Exercises

25. Exercise 1 Mrs. Sita pokharel , 25 yrs old, Primigravida was admitted in the latent phase of labour at 5 AM 2072/10/14: - fetal head 4/5 palpable; - cervix dilated 2 cm; - 3 contractions in 10 minutes, each lasting 20 seconds; - normal maternal and fetal condition.

26. Exercise 1 • At 9 AM: Fetal heart rate; 134/min Membrane: intact Moulding : sutures are not apposed. Fetal head is 3/5 palpable Cervix dilated 5 cm - 4 contractions in 10 minutes, each lasting 20 seconds - Mother’s Pulse: 80/min, BP: 110/70 mm of Hg, Temp: 98°F

27. Exercise 1 9: 30 a.m : FHR 120, contraction 3/10 each 30 seconds, pulse 80/min 10:00 a.m.: FHR 136, contraction 3/10 each 30 seconds, pulse 80/min 10:30 a.m.: FHR 140, contraction 3/10 each 35 seconds, pulse 88/min 11:00 a.m.: FHR 130, contraction 3/10 each 40 seconds, pulse 88/min, Temp: 98 F

28. Exercise 1 11:30 a.m.: FHR 136, contraction 3/10 each 40 seconds, pulse 84/min 12:00 p.m.: FHR 140, contraction 4/10 each 40 seconds, pulse 88/min 12:30 p.m.: FHR 130, contraction 4/10 each 45 seconds, pulse 88/min 1:00 p.m.: FHR 140, contraction 4/10 each 45 seconds, pulse 90/min

29. Exercise 1 • At 1 PM: Fetal heart rate: 140/min Membrane ruptured, amniotic fluid : Clear, Moulding : not present Fetal head is 0/5 palpable; - cervix is fully dilated; 4 contractions in 10 minutes each lasting 45 seconds; spontaneous vaginal delivery occurred at 2:20 PM. Alive male infant weighing 3000gms.

30. Exercise 2 Mrs. Rita Rai was admitted at 10 am on 2072/10/13, Membranes ruptured at 4 am, Gravida 3, Para 2, Hospital number 7886. Fetal head 3/5 palpable above the symphysis pubis Cervix 4 cm dilated 3 contractions in 10 minutes, each lasting 30 seconds FHR :140/min Amniotic fluid: Clear

31. Exercise 2 Sutures apposed Blood pressure: 120/70 mm of Hg Temperature : 98° F Pulse: 80/minute Urine output: 200ml, negative protein and acetone

32. Exercise 2 10: 30 am: FHR 130, contractions 3/10 each 35 sec, Pulse 80/minute 11: 00 am: FHR 136, contractions 3/10 each 40 sec, Pulse 90/minute 11: 30 am: FHR 140, contractions 3/10 each 40 sec, Pulse 88/minute 12: 00 MD: FHR 140, contractions 3/10 each 40 sec, Pulse 90/minute, Temperature 97°F

33. Exercise 2 12: 30 pm: FHR 130, contractions 3/10 each 40 sec, Pulse 90/minute 1: 00 pm: FHR 130, contractions 3/10 each 45 sec, Pulse 88/minute 1:30 pm: FHR 130, contractions 3/10 each 50 sec, Pulse 90/minute 2:00 pm: FHR 130, contractions 4/10 each 45 sec, Pulse 90/minute, Temperature 97°F, Blood pressure 100/70 mm of Hg Fetal head: 3/5 palpab;e , cervix : 6cm dilated, sutures overlapped but reducible

34. Exercise 2 2:30 p.m.: FHR 120, contraction 4/10 each 40 secs , pulse 90/min, clear fluid 3:00 p.m.: FHR 120, contraction 4/10 each 40 secs , pulse 88/min, blood stained fluid 3:30 p.m.: FHR 100, contraction 4/10 each 45 secs , pulse 100/min 4:00 p.m.: FHR 90, contraction 4/10 each 50 secs , pulse 100/min, Temperature 97°F 4:30 p.m.: FHR 96, contraction 4/10 each 50 secs , pulse 100/min 5:00 p.m.: FHR 90, contraction 4/10 each 50 secs , pulse 110/min

35. Exercise 2 At 5:00 p.m.: Fetal head 3/5 palpable above the symphysis pubis Cervix 6 cm dilated Amniotic fluid meconium stained Sutures overlapped and not reducible Urine output 100 ml; protein negative, acetone 1+ Cesearean section at 5:30 p.m., live female infant, weight: 4500gms

36. Exercise 3 Mrs. Sarita ` was admitted at 10 am on 14/10/2072. Membrane Intact Gravida 1 para Hospital no. 1443 The fetal head is 5/5 palpable above the symphysis pubis The cervix is 4 cm dilated 2 contractions in10 minutes, each lasting less than 20 seconds FHR 140/min Membrane - Intact

37. Exercise 3 At 10 am: Blood pressure: 100/70 mm of Hg, Temperature: 97, Pulse: 80/min, Urine output: 400ml, negative: Protein and acetone 10:30 am: FHR:140, contraction 2/10 each 15 sec, Pulse 90/min 11:00 am: FHR: 136, contraction 2/10 each 15 sec, pulse 88/min 11:30 am: FHR: 140, contraction 2/10 each 20 sec, pulse 84/min 12:00 MD: FHR: 136, contraction 2/10 each 20 sec, pulse 88/min, temperature: 98F, fetal head: 5/5 palpable, cervix: 4cm, membrane: intact

38. Exercise 3 12:30 p.m : FHR: 136, contraction 1/10 each 20 sec, pulse 90/min 1:00 p.m : FHR: 140, contraction 2/10 each 20 sec, pulse 84/min 1:30 p.m : FHR: 130, contraction 2/10 each 20 sec, pulse 88 2:00 p.m : FHR: 140, contraction 2/10 each 20 sec, pulse 90/min, Temperature 98F, Blood pressure :100/70 mm of Hg. The fetal head is 5/5 palpable, urine output: 300ml, negative protein and acetone, cervix: 4cm, sutures apposed, Labour augmented with 5 units oxytocin in 500ml RL @10d/min, Membranes artificially ruptured, clear fluid

39. Exercise 3 2:30p.m: 2 contractions in 10 minutes, each lasting 30 seconds, infused rate increased to 20 dpm , FHR;140, pulse 90/min. 3:00 p.m.: 3 contractions in 10 minutes, each lasting 30 seconds, infusion rate: 30d/min, FHR: 140, Pulse: 88/min 3:30 p.m.: 3 contractions in 10 minutes, each lasting 30 seconds, infusion rate: 40d/min, FHR: 140, Pulse: 88/min 4:00 p.m : Fetal head 2/5 palpable, cervix 6cm, sutures apposed, 3 contractions in 10 minutes, each lasting 30 seconds, FHR; 144/min, Pulse: 92/min, Amniotic fluid: Clear

40. Exercise 3 At 4:30 p.m : 3 contractions in 10mins,each lasting 45secs, FHR;140/min, Pulse:90/min, infusion remains at 50d/min At 5:00 p.m : FHR 138, Pulse 92/min, contractions 3/10 each 40 sec, Maintain at 50d/min. At 5:30 p.m : FHR 140, Pulse 94/min, contractions 3/10 each 45 sec, Maintain at 50d/min. At 6:00 p.m : FHR 140, Pulse 96/min, contractions 4/10 each 50 sec, Maintain at 50d/min. At 6:30 p.m : FHR 144, Pulse 94/min, contractions 4/10 each 50 sec, Maintain at 50d/min.

41. Exercise 3 At 7:00 p.m.: Fetal head 0/5 palpable, 4 contractions in 10 minutes, each lasting 50 seconds, FHR; 144/min, pulse: 90/min, cervix fully dilated At 8:10 p.m.: Spontaneous vaginal delivery. a live male infant weighing 2,600 gms

42. Practice doesn’t make man perfect, perfect practice makes man perfect, so keep practising ….