Partograph-Modified

Ppt on modified WHO partograph

1. LABOUR Mrs.Sharmila Jose Lecturer LFCON

2. Partograph

3. Definition It is a composite graphical record of cervical dilatation and descent of head against duration of labour in hours. It also gives information about fetal and maternal conditions that are all recorded on a single sheet of paper. The WHO partograph has been modified to make it simpler and easier to use. The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cm dilated.

4. History The first obstetrician to provide a tool for the assessment of individual labour was Friedman . It was devised in 1954 , based on observations of cervical dilatation and foetal station against time elapsed in hours from onset of labour .

5. Uses of Partograph Early detection of abnormal progress of a labour . Prevention of prolonged labour Recognize cephalopelvic disproportion long before obstructed labour occurs. Assist in early decision on transfer , augmentation , or termination of labour . Increase the quality and regularity of all observations of mother and fetus. Early recognition of maternal or fetal problems.

6. The partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae ) and for the newborn (death, anoxia, infections, etc.). The partograph is used to plot the following parameters for the progress of labor: cervical dilatation, descent of fetal head, and uterine contractions. It will also be used for monitoring fetal conditions with the following parameters: fetal heart rate, membranes and liquor and moulding of fetal skull.

7. Additionally, the partograph can be used to monitor maternal condition: pulse, blood pressure, temperature, urine, drugs, IV fluids, and oxytocin .

8. Functions of Partograph The partograph is designed for use in all maternity settings , but has a different level of function at different levels of health care In health center, the partograph’s critical function is to give early warning if labour is likely to be prolonged and to indicate that the woman should be transferred to hospital (ALERT LINE FUNCTION )

9. In hospital settings, moving to the right of alert line serves as a warning for extra vigilance , but the action line is the critical point at which specific management decisions must be made Other observations on the progress of labour are also recorded on the partograph and are essential features in management of labour

10. Components of the Partograph Patient information Part 1 : Fetal condition ( at top ) Part 11 : Progress of labour ( at middle ) Drugs administered Part 111 : Maternal condition ( at bottom ) Patient information Fill out name, gravida , para , hospital number, date and time of admission and time of ruptured membranes.

11. Part 1 : Fetal condition this part of the graph is used to monitor and assess fetal condition 1 - Fetal heart rate 2 - membranes and liquor 3 - moulding the fetal skull bones Caput

12. Fetal heart rate Basal fetal heart rate < 160 beats/mi =tachycardia > 120 beats/min = bradycardia > 100 beats/min = severe bradycardia Record every half hour.

13. Membranes and liquor Intact membranes ………………………………………. I Ruptured membranes + clear liquor ……………………. C Ruptured membranes + meconium - stained liquor …….. M ruptured membranes + blood – stained liquor ………… B ruptured membranes + absent liquor………………….... A

14. Moulding the fetal skull bones Molding is an important indication of how adequately the pelvis can accommodate the fetal head 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 (reducible 0 ……………………...++ Severely overlapping bones ……..+++ ( non – reducible )

15. Part11 – Progress of labour Cervical dilatation Descent of the fetal head Uterine contractions  

16. Vaginal examination Vaginal examination may be used to assess descent by relating the level of the fetal presenting part to the ischial spines of the maternal pelvis. Vaginal examinations should be carried out at least once every 4 hours during the first stage of labor and after rupture of the membranes. At each vaginal examination, record the following: 1. Color of amniotic fluid; 2.Cervical dilatation; 3. Descent of the presenting part (can also be assessed abdominally).

17. Note: When there is a significant degree of caput or moulding , assessment by abdominal palpation is more useful than assessment by vaginal exam.

18. 1.Cervical dilatation Cervical dilatation assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm. 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.

19. Dilatation of the cervix is measured by the diameter in cm. This is recorded with an X in the center of the partograph , at the intersection of vertical and horizontal lines. The vertical scale represents dilatation by 10 squares of 1 cm each. The horizontal scale represents time by 24 squares of 30 minutes each. When progress of labour is normal and satisfactory , plotting of cervical dilatation remains on the alert line or to left of it.

20. 2. Descent of fetal head: Descent :means that the fetal head descends through the birth canal. The "station" of the fetal head describes how far it has descended through the birth canal. This station is determined relative to the maternal ischial spines (bony prominences on each side of the maternal pelvic sidewalls). Descent of the fetal head may not take place until the cervix has reached about 7 cm of dilatation. This is measured by abdominal palpation and expressed in number of finger widths (fifths of the head) above the pelvic brim. It is also recorded in the central part of the partograph with an "O".

21. Uterine contractions Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. • Less than 20 seconds: • Between 20 and 40 seconds: • More than 40 seconds: Each square represents one contraction

22. Drugs Oxytocin : Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used. Drugs given : Record any additional drugs given.

23. Maternal condition B P : Record every 4 hours and mark with arrows. Pulse : Record every 30 minutes and mark with a dot (.). Temperature: Record every 2 hours. Protein, acetone and urine volume: Record every time urine is passed

24. EXERCISE A primigravida was admitted in the latent phase of labour at 5 AM: - fetal head 4/5 palpable; - cervix dilated 2 cm; - 3 contractions in 10 minutes, each lasting 20 seconds; - normal maternal and fetal condition. Note: This information is not plotted on the partograph .

25. At 9 AM: - fetal head is 3/5 palpable; - cervix dilated 5 cm Note : The woman was in the active phase of labour and this information is plotted on the partograph . Cervical dilatation is plotted on the alert line. - 4 contractions in 10 minutes, each lasting 40 seconds; - cervical dilatation progressed at the rate of 1 cm per hour.

26. At 2 PM: - fetal head is 0/5 palpable; - cervix is fully dilated; - 5 contractions in 10 minutes each lasting 40 seconds; - spontaneous vaginal delivery occurred at 2:20 PM.

27. Management of labour using the Partograph Progress in active phase remains on or left of the alert line Do not augment with oxytocin if latent and active phases go normally Do not intervene unless complications develop Artificial rupture of membranes ( ARM ) No ARM in latent phase ARM at any time in active phase

28. Between alert and action lines In health center , the women must be transferred to a hospital with facilities for cesarean section , unless the cervix is almost fully dilated Observe labor progress for short period before transfer Continue routine observations ARM may be performed if membranes are still intact

29. At or beyond action line Conduct full medical assessment Consider intravenous infusion / bladder catheterization / analgesia Options Deliver by cesarean section if there is fetal distress or obstructed labour Augment with oxytocin by intravenous infusion if there are no contraindications

30. Advantages of Partograph A single sheet of paper can provide details of necessary information at a glance. No need to record labor events repeatedly. It can predict deviation from normal duration of labour early. It facilitates hand over procedure. It reduces the incidence of prolonged labour and caesarean section rate.