Partograph Labour abnormalities1_2.ppt

Labour

1. PARTOGRAPH &
ABNORMAL
LABOUR
PATTERNS
DEJENE A. (MD,
OBESTETRICIAN &
GYNECOLOGIST)
1

2. OUTLINE OF PRESNTATION
Introduction
Methods of labor progress documentation &
monitoring
Advantages of labour monitoring using a Partograph
History, components and of steps in documenting
findings on the partograph
Indicators of labor progress on the partograph
Sample partograph
2

3. OUTLINE...
Definition of abnormal labor (dystocia)
Summary of normal labor
Friedman’s normal labor pattern curve
Incidenceand etiologies(risk factors) of abnormal
labor
Classifications & diagnosis of abnormal labor
Management options of abnormal labor patterns
3

4. INTRODUCTION
Each year >1/2 a million MD occur world wide
~99% of these deaths developing countries
Significant proportion of these deaths follow
prolonged labour (PL)
PL occurs mainly due to CPD & it resultsin:
1.OL
2.Uterine rupture
3.Obstetrics fistula &
4.Less directly in:
a.PPH &
b.Neonatal infection
4

5. INTRODUCTION...
OL is one of the 5major cause of MDin developing c.
5

6. RECORDING OF LABOR EVALUATIONS & IT’S
PROGRESS :
Helps in early detection of abnormal labor &
prevention of prolonged labour:
►↓Maternal & PN M & M.
Two methods:
1.Chart documentation
Findings from the evaluation of the patient are periodically documented on her chart
2.Partographic Monitoring of labor
Documenting labor progress, maternal & fetal status on the partograph
6

7. RECORDING OF LABOR EVALUATIONS &
PROGRESS...
It is the graphic recording of the progress of
labour and the condition of the mother and
the fetus
It serves as an “early warning system” and
assists in early decision to:
Transfer,
Augmentation &
Termination of labour
7

8. ADVANTAGES OF PARTOGRAPH
I.Pictorial display of events of labor, thus
1.Clarifies recordings
2.Avoids lengthy written notes
3.Facilitates recognition of any omissions
4.Saves time → Companionship
II.Considerable educational value
All interrelated variables of labor can be seen on a single paper
III.Low cost, feasible
IV.Easy documentation of findings
V.Quick evaluation of findings
8

9. ADVANTAGES OF PARTOGRAPH ...
Easy handing over of many laboring mothers
Can be easily understood by midlevel health
workers ( clear & easy indicators for referral)
Suitable for research purposes
Clear landmarks to assess when labor progress is
delayed( alert and action lines)
Prevention of prolonged labor
Avoids unnecessary use of augmentation
Improves out come of labor →↑Credibility of
formal health sector
9

10. ADVANTAGE OF PARTOGRAPH:
EVIDENCE/WHO TRIAL
WHO multicenter study, >35,000 women, 1990
Outcomes
Before
Implementation
After
Implementation
p
Labor > 18 hrs 6.4% 3.4% 0.002
Labor augmented 20.7% 9.1% 0.023
Postpartum
sepsis
0.70% 0.21% 0.028
Spontaneous
cephalic
83.9% 86.3% < 0.001
Emergency C/S 9.9% 8.7% 0.628
Forceps 3.4% 2.5% 0.005
Intrapartum still
births
0.50% 0.30% 0.024
10

11. HISTORY OF PARTOGRAPH
In 1954 E. A. Freidman, following a study in a large
number of women in USA described a normalCxdilation
First to show plottingCxdilation Vs time
His work has been a foundation on which others built...
He divided labour functionally into:
1.Early (latent phase)
Extends over 8-10hrs
Up to 3cm Cxdilation
2.Active phase
Characterized by acceleration from about 3-10cm at the end of which deceleration occurs
11

12. HISTORY OF PARTOGRAPH ...
12

13. HISTORY OF PARTOGRAPH ...
The WHO partograph (1987)
Safe motherhood conference in 1987 “A call to action”

The health workers involved in the care of mothers &
children take positive action to reduceM M&M.

“All pregnant women in labor are managed by:
oAppropriately trained personnel using practical & relevant technology”

One of which is the partograph
13

14. 14

15. THE WHO PARTOGRAPH ...
Principles:
1.The active phase commences at 3 cm cxdilation
2.The latent phase should not last >8 hrs
3.During active phase, the rate of Cxdilation
shouldn't be <1cm/hr
4.Vxexamination
Infrequently as compatible with safe practice (Q 4 hrs is recommended)
5.Health personnel managing labor may have difficulty
in constructing alert & action line ►pre-drawn lines
15

16. THE WHO PARTOGRAPH ...
It has been modified to make it
simpler &easier to use(2001)
The latent phase has been removed &
plotting begins in the active phase
when the cx is 4 cm dilated
16

17. MODIFIED WHO PARTOGRAPH
17

18. MODIFIED WHO PARTOGRAPH
18
I II

19. USE OF THE PARTOGRAPH
Partograph is used for the assessment of:
Fetal well being
Maternal well being
Progress of labor
USING THE PARTOGRAPH
19

20. PARTS OFWHO PARTOGRAPH
It has four Parts:
1. Patient information
2. Fetal condition
3. Progress of labour
4. Maternal condition
20

21. COMPONENTS OF PARTOGRAPH
Section Component Instructionsfor
filling:
I.Patient
informations
oIdentificationName
Hospitalnumber
Date & time of
admission
oReproductive
Performance
Gravidity
Parity
oMembrane
condition
Time of rupture
of membranes
21

22. COMPONENTS ...
Section Component Instructionsfor filling:
II.Fetal
1.FHR
oCount Q 30’
Indicatedwith a dot ()
2.Liquor
oColor of AF at
QV/E
I-Intact membranes;
C-clear liquor;
M-meconium stained
B-Blood stained
3.Molding
oDegreeof
moldingat Q
V/E
0,
+1(apposed),
+2( reducibleoverlap),
+3 (irreducible overlap)
22

23. LABOUR PROGRESS …
Alert line:
A line starts @4 cm of cervical dilatation to the point
of expected full dilatation @the rate of 1 cm/hour.
Action line:
Parallel & 4 hrs to the right of the alert line.
Hours:
Refers to the time elapsed since onset of active phase
of labour (observed or extrapolated).
Time:
Record actual time.
23

24. COMPONENTS ...
Section ComponentInstructionsfor filling:
III.Labor
progress
1.Cervical
dilatation
oAssessed @
QV/E
Indicated by-‘X’
Start plotting on the action line
At Cx dilataion of ≥4cms(in
active phase of 1st stage of
labour)
2.Descent
oAssessed @
QV/E
Indicated by ‘o’
It is the a measure of fetal
head palpable above symphysis
pubis Slide 73
3.Uterine
contractions
Number,
Intensity&
DurationUterine Contractions...
24

25. UTERINE
CONTRACTIONS...
Contractions:
Chart Q 1/2 hrs;
Palpate the number of contractions in 10’& their duration in seconds:
o< 20’’; mark with
oB/n 20 & 40’’; mark with
o> 40’’; mark with
25

26. COMPONENTS ...
Section Component Instructionsfor filling:
IV.Mat.
Cond.
1.Vital signs BP indicate by –“” & record
Q 4hrs
PRindicate by –“”& record Q
30’
Tempratre in °C& record Q 2
hrs
2.Urine outputProtein, acetone &volume
Record Q time urine is passed.
3.MedicationsOxytocin:
Amount per volume IV
fluids in dpmQ30’
Drugs given: Anyadditional
drugs given. 26

27. STEPS IN FILLING THE
PARTOGRAPH
STEPDESCRIPTION
1 Cervical dilatation-
@dilatation of≥ 4cms,
Start plotting on the action line
Mark with “X”
2 Time
On the same vertical line as the cervical dilatation
3 Descent-filled on the same vertical line as the cervical
dilatation
5th of fetal head palpable above the symphysis pubis
Mark with “O”
4 Uterine contractions-
Filled by covering the number of verticalsqurescorresponding to
the number of contractions;
Shading
27

28. STEPS...
StepDescription
5 Fetal condition
On the same vertical line as the cervical dilatation
6 Maternal condition
Filledon the same vertical line as the cervical
dilatation
7 Repeat evaluation:
performedand filled four hours later or more
frequently as indicated
28

29. INDICATORS OF LABOR PROGRESS ON
THE PARTOGRAPH
Alert line-Cxdilatation of the least progressing 10%
of primi’swho had SVD
oA rate of 1cm/hr
oAny progress <1cm/hr( crosses alert line ) -Slow
progress
Further evaluation as to the specific cause,OR
Referral
Action line –an arbitrary line four hours parallel and
to the right of the action line
oIf labor progress crosses the action line
significant delay and needs urgent evaluation & intervention
29

30. FOR WHOM TO USE A PARTHOGRAPH
1
st
make sure that:-
There are no complications of pregnancy that require
immediate action
The women is in labor
False labor is R/o & the partiunent in active phase of
1st stage of labour
It can be used for all labors:
In a hospital (including breech, multiple pregnancy,
previous C/S...)
In the peripheral health units
Inductions & augmentations –begin filling the
partograph when labor is established
Not in 2nd stage of labour
30

31. SAMPLE PARTOGRAPH FOR NORMAL LABOR
31

32. PARTOGRAPH SHOWING OL
32

33. PARTOGRAPH SHOWING INADEQUATE U
X
CONTRACTIONS CORRECTED WITH OXYTOCIN
33

34. 34
DYSTOCIA
Synonyms:
oDifficult labor /Abnormal labor pattern

35. DYSTOCIA
Any labor in which the pattern of labor progress is
significantly different from accepted &recognized
patterns of labor progress in terms of:
Cervical changes,
Decent of fetal presenting part or
Profile of uterine contractions
35

36. NORMAL LABOR
Dynamic process
Uterine contractions that increase in :
Regularity
Intensity and
Duration
Causing progressive dilatation & effacement of the cervix
Permit descent of the fetus through the birth canal
9/8/2022 36

37. NORMAL LABOR…
Normallaborischaracterizedby:
1.Spontaneousonset
2.Rhythmicandregularuterinecontraction
3.Vertexpresentation
4.Vaginaldeliverywithoutactiveinterventions
5.Reasonabletime
6.Nomaternalorfetalcomplications

38. FRIEDMAN’S NORMAL LABOR
PATTERN CURVE
Friedman describid normal labor pattern in
primigravidsand multíparas in 1950’s
Usingthe95
th
percentil valué as theupperlimitof
normal, he described4 abnormal patternsof labor
He divided labor into three functional divisions:
1.The preparatory division,
2.Dilation division, and
3.Pelvic division
Sigmoidcurve
9/8/2022 38
first stage of labor
second stage of labor

39. 39

40. FRIEDMAN’S CURVE FOR NULLIPARA –
CERVICAL DILATATION AND DESCENT
9/8/2022 400
1
2
3
4
5
6
7
8
9
10
01234567891011121314151617181920
tiempo en trabajo de parto (hrs)
dilatación cervical (cm)
Acceleration
Phase of
maximum
slope
Deceleration
Latent phase
Active phase
2
nd
Stage

41. ETIOLOGIES OF ABNORMAL LABOR
Related to one of the four p’s of labor determinants–4
p’s
Abnormalities of :
1.Powers
2.Passage
3.Passanger
4.Psychologicology
9/8/2022 41

42. ETIOLOGIES OF ABNORMAL LABOR ...
1)Abnormalities of the powers
oPrimary power –uterine contraction
oSecondary power –maternal expulsive efforts…
2)Abnormalities of the passages
oContraction of the bony pelvis –inlet, midpelvic , outlet
oSoft tissue dystocia –tumor previa, vaginal septa etc
3)Abnormalities of the passenger
4)Psychological factors
oOften due to stress of labor affecting autonomic
nervous system
42

43. ETIOLOGIES…
Abnormalities of the power–
Primary uterine inertia –
oAbnormal uterine contraction frequencies, duration &intensity
that is due to inherent myometrial dysfunction
oMainly affects primigravid labors without other additional
factors
Secondary uterine inertia –causes
oProlonged labor
oMalpresentations/ malpositions
oEpidural analgesia
oUterine myomata
oDehydration and electrolyte imbalances
oFetopelvic disproportion
oAbruptio placentae with couvaliare uterus
43

44. ABNORMALITIES OF THE PASSENGER
(FETUS) LEADING TO DYSTOCIA
Macrosomia
Multifetal gestation
Congenital anomalies –e.g. hydrocephalus
Malpresentations/ Malpositions
44

45. INCIDENCE
Nulliparas-25% of all labors
Multiparas-10% of all labors
40% of the indications for C/S,(EUA, 1994)
o50% of primary C/S
o21% of repeat C/S
45

46. CLASSIFICATIONS OF ABNORMAL
LABOR PATTERNS –
Four major groups:
1)Prolongation disorders
2)Protraction disorders
3)Arrest Disorders
4)Precipitate labor
46

47. PROLONGATION DISORDERS
Only one prolongation disorder recognized in 1
st
stage
Disorders of the Latent Phase
oA latent phase lasting >14 hrs in a multigravida &20 hrs in a
primigravida
oChallenge in diagnosis is often due to the problem in
diagnosing the exact time of onset of labor
The 95
th
%ilesfor maximum length in latent labor:
o20 hours for nulliparous & 14 hours for multiparous
oThe upper limits for time spent in latent labor
Mean duration of latent labor:
Nullipara-6.4 hrs&
Multi –4.8 hrs
47

48. PROTRACTION DISORDERS
Two protraction disorders
1.Protracted cervical dilatation
oA cervical dilatation <1.2 cms in the multigravida and
1.5 cms in the primigravida during active labor
2.Protracted descent
oDescent of the fetal presentation less than 1 cms per
hour in the multigravida and 2 cms per hour in the
primigravida
48

49. ARREST DISORDERS
a)Prolonged deceleration Phase
Deceleration phase > 3 hrs in nullipara
> 1 hr in Multi
b)Secondary arrest of dilatation
No progressive cervical dilatation for 2 hrs or more
c)Arrest of descent (Failure of descent)
Descent fails to progress for > 1 hr
Descent fails to occur in the deceleration phase
49

50. DISORDERS OF THE SECOND STAGE
The median duration of the second stage is 50 to 60 minutes
for nulliparas and 20 to 30 minutes for multiparas
Factors influencing the length of the second stage include
parity, maternal size, birth weight, OP position, fetal station
at complete dilation, and, potentially, conduction anesthesia
For nulliparous women, the diagnosis should be considered
when the second stage exceeds 3 hours if regional anesthesia
has been administered or 2 hours if no regional anesthesia is
used, and in multiparous women, the diagnosis can be made
when the second stage exceeds 2 hours with regional
anesthesia or 1 hour without
50

51. PRECIPITATE LABOR
Precipitous labor refers to delivery of the infant in less
than 3 hours
This occurs in approximately 2% of all deliveries
Short labors can be associated with placental abruption,
uterine tachysystole, and recent maternal cocaine use—
all of which are major contributors to poor outcomes for
mothers and infants
Two precipitate labor disorders
a)Precipitate dilatation
Primigravida> 5 cm/hr
Multigravida > 10 cm/hr
b)Precipitate descent
Primigravida> 5 cm/hr
Multigravida > 10 cm/hr
51

52. DIAGNOSIS
History& Physicalexamination
Partograph
Document the following parameters against time
oUterine contraction profile
oCervical dilatation/effacement
oDescent of fetal presentation
Compare against normal patterns for respective parity, identify any
deviations and then classify into respective abnormal patterns
Look for specific etiology responsible for the abnormal
labor patterns by:
oCarefully assess the 4determinants of labor progress (P’s
of labor)
52

53. EVALUATION FOR CAUSES OF ABNORMAL LABOR
PATTERNS –ASSESSMENT OF THE 4P’S OF
LABOR
Assessment of powersof labor –three ways
1)Palpation of uterine contractions
2)External tocodynamometer
3)Intrauterine pressure catheter monitoring
oMaternal exhaustion, vital signs, blood glucose and
evidence of dehydration
Assessment of the passenger
oSize, number, presentation, position and anomalies of
the fetus by Leopold's palpations & ultrasonography
Assessment of the passages
oBony pelvis –clinical pelvimetry
oSoft tissue dystocia –vaginal exam
Assessment of maternal emotionalstatus and pain
control
53

54. MANAGEMENT OF ABNORMAL LABOR –
DEPENDS ON SPECIFIC ETIOLOGY DIAGNOSED
Power abnormalities
Uterine inertia –Augmentation
Secondary powers failure –Instrumental assistance
Passenger abnormalities
Often caesarean deliveries required
Destructive deliveries in cases of fetal deaths
Abnormalities of the passages
Often Caesarean delivery
Episiotomy for perineal level obstruction
54

55. 9/8/2022 55

56. SUMMARY
56

57. CAUSES OF DYSTOCIA
Abnormalities of the
passage:
Pelvic Dystocia:
Bony pelvis -contracted
pelvis
Soft tissues
abnormalities
Fetal Dystocia:
Excessive size
Malposition
Congenital anomalies
Multiple gestation
57
Uterine Dystocia:
Hypotonia
Hypertonia
Lack of voluntary expulsive effort in 2
nd
stage
Abnormalities of the
passager:
Abnormalities of the power:

58. 58

59. 59