Partograph and labor dystocia for undergraduate

undergraduate course lectures in ob&gyne prepared by DR Manal Behery.Professor of OB&GYNE.Faculty of medicine,ZAGAZIG University

1. Partograph Partograph

2. PartographPartograph
A partograph is a graphical
record of the observations made
of a women in labor
For progress of labor and
conditions of the mother and
the fetus

3. History Of PartogramHistory Of Partogram
Friedman's partogram

Cervical dilatation and fetal
station against time in hours
from onset of labour.yielded
the typical sigmoid or 'S'
shaped curve

4. ObjectivesObjectives
 early detection of abnormal progress of a labour
prevention of prolonged labour
 Recognize cephalo pelvic disproportion long before
obstructed labour
Assist in early decision on transfer , augmentation , or
termination of labour
Early recognition of maternal or fetal problems

5. Components of the partographComponents of the partograph
Part 1 : fetal condition ( at top )
Part 2 : progress of labour ( at middle )
Part 3 : maternal condition ( at bottom )

6. Mother information
Fetal well-being

• Fetal heart rate
• Character of liquor
• Moulding
Labour progress

• Dilatation
• Descent
• Uterine contraction
Medications
• Oxytocin
• Pain relief (e.g. pethidine)
Maternal well-being

• BP, Pulse, Temperature
• Urine – albumin, glucose, acetone
• Urine output

7. Part 1 : Fetal condition Part 1 : Fetal condition
Recording fetal heart rateRecording fetal heart rate

8. Membranes and liquorMembranes and liquor
Dilated cervix with bag of fore water
I: intact
C : clear
M : muconium
B : blood stained

9. Molding the fetal skull bonesMolding the fetal skull bones
. Increasing molding with the head high in the pelvis is an ominous
sign of Cephalopelvic disproportion.
separated bones . sutures felt easily……….O
bones just touching each other…………… ..+
overlapping bones …………… ………… ...++
severely overlapping bones ( notable ) ……..+++

10. Part 2 – progress of labourPart 2 – progress of labour
. Cervical dilatation: it is divided into a latent phase and an
active phase
Descent of the fetal head
Uterine contractions

11. Cervical dilatationCervical dilatation
It is the surest way to assess progress of labour

12. latent phase latent phase
Starts from onset of labour until the cervix reaches 3
cm dilatation
lasts 8 hours or less
Contractions at least 2/10 min contractions
each lasting < 20 seconds

13. Active phase :Active phase :
The cervix should dilate at a rate of 1 cm / hour
or faster
Contractions at least 3 / 10 min each lasting < 40
seconds

14. Alert line ( health facility line )Alert line ( health facility line )
The alert line drawn from 3 cm dilatation
represents the rate of dilatation of 1 cm / hour
Moving to the right or the alert line means
referral to hospital for extra care

15. Action line ( hospital line )Action line ( hospital line )
The action line is drawn 4 hour to the right
of the alert line and parallel to it
This is the critical line at which specific
management decisions must be made at the
hospital

16. When labor goes from latent to active phase , plotting of
the dilatation is immediately transferred from the latent
phase area to the alert line

17. Abnormal labor progress Abnormal labor progress

18. Descent of the fetal headDescent of the fetal head
The rule of fifth BY abdominal examination

19. Assessing descent of the fetal PV;Assessing descent of the fetal PV;
0 station is at the level of the ischial spine 0 station is at the level of the ischial spine

20. Recording uterine contractionRecording uterine contraction

21. PART 3:Recording of maternal PART 3:Recording of maternal
conditioncondition

22. --


23. Abnormal labor and DystociaAbnormal labor and Dystocia
One of the main functions of the partograph is to
detect early deviation from normal progress of labor

24. 0
2
4
6
8
10
12
2 4 6 8 10 12 14 16
Latent phase
Active phase
2nd
stage1st stage
max slope
acceleration
dec
Time (hours)
Cervical dilatation
(cm)
Friedman labor curve in nulliparous

25. Normal progress in labor Normal progress in labor

26. A prolonged latent phase
B prolonged active phase
C arrest active phase
Abnormal progress in labor

27. Prolonged latent phaseProlonged latent phase
?????? Nulliparas
Multiparas
prolonged
>20 hr
> 14 hr
Normal average
6.4 hr
4.8 hr

28. Management Management
Prolong Latent Phase Prolong Latent Phase
–Simple analgesia
–Encourage mobilizati on
–Reassurance
–ARM and oxytocin will cause poor progress
later

29. Protraction disordersProtraction disorders
?????? Nulliparas
Multiparas
Descent
<1.0 cm/h
<2.0 cm/h
Dilation
<1.2 cm/h
<1.5 cm/h
Average
8hr
5hr

30. Arrest disorderArrest disorder
?????? Nulliparas
Multiparas
Descent
>2h
>1h
Dilation
>2h
>1h

32. Causes of Protraction disordersCauses of Protraction disorders
??????
minor malpositions such as occiput posterior.
improperly administered conduction
anesthesia. ,excessive sedation.
Fetopelvic disproportion.

33. Treatment of protraction and Treatment of protraction and
arrest disorderarrest disorder
Cesarean section is indicated in the presence
of confirmed fetopelvic disproportion.
In the absence of fetopelvic disproportion,
support and close observation
oxytocin augmentation

34. Critical
Factors
Psyche Powers
Passenger
Passageway
Dysfunctional Labor is related to
Abnormalities of the Critical Factors:

35. Psychology of birthPsychology of birth
The progress of labor and birth can be
adversely affected maternal fear and tension.
Norepinephrine and epinephrine may stimulate
both alpha and beta receptors of the
myometrium and interfere with the rhythmic
nature of labor.
Anxiety can also increase pain perception and
lead to an increased need for analgesia &
anesthesia.

36. Characteristics of theCharacteristics of the powerpower
Intensity is greater in the fundus
Average 24mmHg
Well synchronized
Frequency
Duration 60s
regular
Rhythm and force
Basal resting pressure 12-15mmHg

37. Fetal monitoringFetal monitoring

38. Friedman’s GraphFriedman’s Graph
Hypotonic Uterine ContractionsHypotonic Uterine Contractions
Prolonged active phase
Normal
Curve

39. Therapeutic InterventionsTherapeutic Interventions
–Ambulation
–Nipple Stimulation --release of endogenous Pitocin
–Enema--warmth of enema may stimulate contractions
–Amniotomy--artificial rupture of the membranes
–Augmentation of labor with Pitocin

40. AmniotomyAmniotomy
Amniotomy is the artificial rupture of the amniotic
sac with a tool called the amniohook
# 1-Check the fetal heart tones
–Assess color, odor, amount
–Provide with perineal care
–Monitor contractions
–Check temperature every 2 hours

41. Hypertonic and uncoordinated Hypertonic and uncoordinated
dysfunctiondysfunction
Resting tone
Dyssynchronous
Frequent intense contraction
Constriction ring
Tocolysis
Decrease oxytocin
Cesarean section
Sedation

42. Friedman’s GraphFriedman’s Graph
Hypertonic Uterine ContractionsHypertonic Uterine Contractions
Prolonged latent
phase

44. Cephalopelvic Disportion (CPD)Cephalopelvic Disportion (CPD)
Causes
–Large baby or small pelvis
–Usually diagnosed when there is an arrest in descent
Symptoms
–Station remains the same does not descend
Treatment
–Usually do a cesarean delivery if cause is pelvis
–Utilize other measures such as forceps, vacuum
extraction, episiotomy.

46. Pelvi- Latin word pelvis (basin)
Metron - Greek word for measure
Pelvimetry means to measure the pelvis.

48. Three level of bony pelvisThree level of bony pelvis

49. Measuring diagonal conjugate
 Insert two fingers into the vagina until they reach the
sacral promontory.
The distance from the sacral promontory to the exterior
portion of the symphysis is the diagonal conjugate and
should be greater than 11.5 cm.
 Unengaged fetal head

52. • Feel the ischial spines for their relative
prominence or flatness.
• Ischial prominence narrows the transverse
diameter of the pelvis.
• Feel the pelvic sidewalls to determine
whether they are parallel (OK), diverging
(even better), or converging (bad).
• Narrow sacrosciatic notch

54.  Measure the bony outlet by pressing your
closed fist against the perineum.
Greater than 8 cm bituberous ( or transverse
outlet) is considered normal.
Narrow pubic arch<90