Partograph- Made easy for undergraduates

Partograph is very important tool for monitoring the progress of labour. In this presentation it is very easily expalined how to plot a partograph.

1. Partograph- Made easy for undergraduates Dr. Debraj Mondal MBBS, MS, DNB, MRCOG (1)-UK

2. What is Partograph or Partogram ? Is a tool which graphically represents key events during labour. The partograph is an inexpensive and accessible tool that can effectively monitor the progress of labour

3. Objectives to improve health care and To reduce maternal and fetal morbidity and death.

4. Why should we use a partograph ?

5. First Obstetrician to describe the progress of labour graphically E.A. Friedman was the first obstetrician to describe the progress of labour graphically in 1954. He reported the change in cervical dilatation occurring in labour. The progress was recorded in centimetres of dilatation per hour. The resulting graph was an S-shaped curve.

6. Types of partographs : Philpott and Castle developed a partograph , a practical tool for recording all intrapartum details, not just cervical dilatation Since the 1990's, WHO has published three different types of the partograph

7. A. The composite partograph --1994 A latent phase of 8 hr An active phase starting at 3 cm cervical dilatation .

8. B. The modified WHO partograph for use in hospitals was published in 2000 No latent phase Active labour starts from 4 cm

9. 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 ).

10. Why latent phase is removed Latent phase is most often a "retrospective diagnosis ". Having a arbitrary time limit for latent phase of 8 h increases the risk of incorrect diagnosis of labour and could thus increase the risk of non-indicated interventions and morbidity . On the other hand, the risks of "prolonged latent phase" in the presence of intact membranes and no other complications is almost minimal. Lastly , the "transfer" from latent to active phase (broken line) by health workers was reportedly a major source of confusion and error in partography .

11. Observations charted on the Partograph A) The Progress of labour Cervical dilatation Descent of fetal head Uterine contractions – duration, frequency B) Fetal condition Fetal heart rate Membranes and liquor Moulding of the fetal skull C) Maternal condition Pulse/ BP / Temp Urine – volume, acetone, protein Drugs & IV Fluids Oxytocin regime

12. 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

13. Starting a Partograph 1 st part is patient particulars. Name, Gravida , Para, Hosp. No. DOA, TOA Ruptured membrane, Hours

14. Cervical dilatation Assessed only after 4 cm dilatation. Plotted every 4 hr Marked with “X” on the cervi -graph

15. What is alert line ? an oblique line on the Cervical Dilatation Area of the partograph that goes from 4 to 10 cm of cervical dilatation Represents the rate of cervical dilatation 1 cm per hour. This rate is considered to be the slowest rate of cervical dilatation among nulliparae in normal labour.

16. What is action line ? An oblique line in the Cervical Dilatation Area of the partograph 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. In this case, full medical assessment must be performed and decision must be made about the cause of the slow progress, and appropriate action taken

17. Recommendations for taking action

18. left 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

19. Between Alert and Action lines In a Health Centre: Transfer to hospital with facilities for Cesarean section, unless Cervix is almost fully dilated 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 continue routine observations

20. At or Beyond Active Phase Action Line Full medical assessment Consider IV infusion/bladder catheterization/analgesia Options: Delivery if fetal distress or obstructed labour Oxytocin augmentation if no contraindication Supportive therapy (only if satisfactory progress is now established and dilatation could be anticipated at 1cm/ hr or faster)

21. Descent of fetal head It is measured in terms of fifths above the pelvic brim The width of the 5 fingers is a guide to the expression in fifths of the head above the brim. A head that is mobile above the brim will accommodate the full width of 5 fingers Plotted with “0” on the lower part of cervicograph .

22. As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers

23. It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 fingers are less

24. Uterine contractions Calculated per 10 min. Weak (<20 sec) Dots. Moderate (20 – 40 sec) Crosshatchs . Strong (>40 sec) Darkened. Weak Moderate Strong

25. Fetal condition Fetal Heart rate Status of the membranes Moulding

26. Fetal Heart Rate Listen Patient in left lateral position Just after the contraction has passed its strongest phase For 1 full minute , every 30 min if abnormal every 15mins If abnormal over 3 observations, take action Record At the top of the Partograph Every half hour

27. 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

28. Membranes & Liquor State of Liquor Record Membranes intact I Clear C Meconium M Absent A Blood Stained B

29. Fetal condition- Moulding Sagittal suture Metopic suture Coronal suture Anterior Frontanelle

30. Fetal condition- Moulding State of Moulding Record Bones are separated & sutures felt O Bones are just touching each other 1+ Bones are overlapping 2 + Bones are severely overlapping and not separable 3+

31. Lower part of Parograph Drugs Vitals

32. Drugs Recorded at the foot of the Partograph Oxytocin : IV Fluids Other Drugs : Drotin , Epidosin , Tramadol , Pethidine , Epidural

33. 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. Is 5 Unit per Litre (5 U/L)

34. Oxytocin dose calculation 15 drops is equivalent to 1ml of fluid. Suppose we have taken oxytocin@5 U/L Each Litre of fluid contains 5 unit drug Each Litre of fluid contains 5000 mili -unit ( mU ) Each ml of fluid contains 5 mili -unit ( mU ) Each 15 drops of fluid contains 5mU The rate is 15 drops per min to start with.

35. Maternal Condition Recorded at the foot of the Partograph Pulse : every half hour BP : every 4 hrs or more frequently Temp : every 4 hrs or more frequently Urine : Protein , Acetone,Volume

36. Can the partograph be used only for normal ( vertex) presentation ? Use of the partograph is not restricted to vertex presentations. It can be used in all situations where vaginal birth can be expected. For example, it can be used in monitoring progress of labour in breech presentation . However in this situation, descent of the fetal head and moulding are not assessed and recorded on the partograph . The partograph can also be used in face presentation . Vaginal birth is not anticipated with transverse lie and brow presentation and hence the partograph is not used.

37. How should the labour progress be monitored in second stage of labour ? The condition of mother and the fetus should be monitored more frequently in the second stage of labour. The cervix is fully dilated and while 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.

38. Inadequate uterine contractions corrected with oxytocin Q.1

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