partograph.pptx

designed by who and its history uses and application

1. partograph Presenter: Dr Sharwajeet jha

2. definition partograph is a composite graphical record of key data (maternal and fetal) during labor, entered against time on a single sheet of paper. it is similar for nulliparas and multiparas. it was designed by who for use in developing countries. can serve as an “early warning system” and assist in making decision and interventions

3. History of partograph F riedman’s partograph devised in 1954 was based on observation of cervical dilatation and fetal station against time elapsed from onset of labour . T he time of onset of labour was based on patient subjective perception of her contractility. p lotting cervical dilatation against time

4. Philpott and Castle Introduced the concept of "ALERT" and "ACTION' lines. The alert line represented the mean rate of slowest progress of labour (1cm/ hr ) starting at zero time i.e. Time of admission . Action line drawn four hours to the right of the alert line and parallel to it. showing that if the patient has crossed the alert line active management should be instituted within 4 hours, enabling the transfer of the patient to a specialized tertiary care center.

5. Studd's labour stencils(1972) These stencils predicted the expected pattern of progression of labour based on the extent of dilatation achieved by the time the patient is admitted (zero time). Curves showing the average course of cervical dilatation were constructed for various dilatation on admission. Five separate patterns representing normal labour progression were constructed. The cure were transcribed onto acrylic stencils admission in labour , the cervical dilatation was assessed and a stencil was used to draw the relevant pencil line of expected progress on the patient's Which was then complete those crossing the nomogram line were found to have a three fold increase in instrumental delivery .

6. Who partograph Has been modified in 2000 making it simpler and easier to use The latent phase has been removed Plottig in the graph begins in the active phase when the cervix is 4 cm dilated.

7. Objectives Early detection of abnormal progress of a labour prevention of prolonged labour Recognize cephalopelvic disproportion long before obstructed labour 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 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.).

8. Partograph function The partograph is designed for use in all maternity settings , but has a different level offunction 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 ) 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

9. Advantages of a partograph (I) A single sheet of paper can provide details of necessary information at a glance (II) no need to record labor events repeatedly (III) it can predict deviation from normal progress of labor early. So, appropriate steps could be taken in time (IV) it facilitates handover procedure (V) introduction of partograph in the management of labor (WHO 1994) has reduced the incidence of prolonged labor and cesarean section rate. There is improvement in maternal morbidity, perinatal morbidity and mortality.

10. Components of the partograph Patient identification Date and time Part 1: fetal condition (at the top) Part 2 : progress of labour ( at the middle) Part3:maternal condition (at bottom)

11. 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

12. Fetal heart rate Baseline heart rate is best determined over 5-10 min Normal :110-160 beats/min Recorded at every 30 minutes

13. State of membrane and colour of liquor To mark ‘I’ for Intact membranes= I Ruptured membrane + clear liquor=C ‘Ruptured membrane + meconium stained liquor=M Ruptured membrane + blood stained liquor=B Ruptured membrane + absent liquor = A

14. Moulding the fetal skull bones Moulding is an important indication of how adequately the pelvis can accommodate the fetal head I ncreasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion Separated bones -sutures felt easily = 0 Bones just touching each other = + Overlapping bones ( reducible) = ++ Severely overlapping bones ( non - reducible) = +++

15. Part 2: progress of labour Cervical dilatation Descent of the fetal head Fetal position Uterine contractions This section of the partograph has as its central feature: a graph of cervical dilatation against time

16. Phase of labour Latent phase: It starts from onset of labour until the cervix reaches 4 cm dilatation , Once 4 cm dilatation is reached , labour enters the active phase. Active phase : Contractions at least 3 / 10 min each lasting > 40 seconds The cervix should dilate at a rate of 1 cm / hour or faster

17. Alert line ( health facility line ) The alert line drawn from 4 cm dilatation represents the rate of dilatation of 1cm / hour Moving to the right of the alert line means referral to hospital for extra vigilance

18. 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 decisions must be line at which specific management made at the hospital

19. Cervical dilatation It is the most important information and the surest way to assess progress of labour , even though other findings discovered on vaginal examination are also important When progress of labour is normal and satisfactory , plotting of cervical dilatation remains on the alert line or to the left of it If a woman arrives in the active phase of labour , recording of cervical dilatation starts on the alert line

20. Descent of fetal head It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement The rule of fifth means the palpable fifth of the fetal head felt by abdominal examination to be above the level of symphysis pubis When 3/5 or less of fetal head is felt above the level of symphysis pubis , this means that the head is engaged , And by vaginal examination , the lowest part of vertex has passed or is at the level of ischial spines .

21. Uterine contractions Observations of the contractions are made every half-hour in the active phase Frequency how often are they felt ? assessed by number of contractions in a 10 minutes period e duration How long do they last ? Measured in seconds from the time the contraction is first felt abdominally , to the time the contraction phases off Each square represents one contraction

22. Methods of assessment of uterine contractions 1. Manual assessment 2. Cardiotocography The above methods measure the frequency and duration of contractions 3. Intrauterine catheters to measure intrauterine pressure in montevido units This method will measure the intensity in addition to frequency and duration

23. Part 3: maternal condition Assess maternal condition regularly by monitoring : Drugs , IV fluids , and oxytocin , if labour is augmented Pulse , blood pressure e temperature Urine volume, analysis for protein and acetone

24. Drugs : as given Fluids: type and amount used Maternal pulse: recorded every half hourly (marked with dot) Blood pressure : every 2 hourly (in vertical line)(marked with arrows) Oxytocin concentration in upper box Oxytocin doses in lower box Urine evaluation: for acetone, protein (every time urine is passed) Temperature record: every 2 hourly

25. Management of labour using partograph Progress in active phase remain on or left of the alert line Do not augment with oxytocin if latent and active phases go normally No ARM in latent phase ARM at any time in the active phase

26. Between alert and action lines   In health center , the women must be transferred toa 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

27. beyond action 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

28. ABNORMAL PROGRESS OF LABOUR One of the main functions of the partograph is to detect early deviation from normal progress of labor

29. Moving to the right of alert line This means warning Transfer the woman from health center to hospital Reaching the action line this means possible danger Decision needed on future management (usually by obstetrician or resident )

30. Prolonged latent phase It is prolonged when its duration exceeds 20 hours in primigravida and 14 hours in multigravida According to who partograph , a prolong latent phase is “cervix not dilated beyond 4 cm after 8 hour from duration”

31. Prolonged latent phase management Expectant Awaiting active labour - provided no indication for delivery Simple analgesics, mobilization, reassurance Active management If delivery indicated- induction/augmentation of delivery Early arm- increased the risk of prolonged labour with PPROM- risk of intrauterine infection, neonatal sepsis, 10 fold risk of CS

32. Prolonged active phase Plotting of cervical dilatation will normally remain on or to the left of alert line Moves to the right of alert line- warns labour may be prolonged Happens if cervical dilatation <1cm / hr within 4 hours At action line, women should be carefully reassessed for why labour is not progressing and a decision made on further management.

33. Secondary arrest of cervical dilatation Abnormal progress of labor may occur in cases with normal progress of cervical dilatation then followed by secondary arrest of dilatation When the cervical dilatation commences normally but stops or slows significantly for 2 hours or more , prior to full dilatation of cervix

34. secondary arrest of descent of fetal head Abnormal progress of labor may occur with normal progress of descent of the fetal head then followed by secondary arrest of descent of fetal head

35. Prolongd 2 nd stage of labour Definition Primigravida >2 hours without epidural anesthesia >3 hour with anesthesia Multigravida >1 hours without epidural anesthesia >2 hour with anesthesia

36. Protraction of descent: Descent of presenting part during the 2 nd stage of labour occurring at <1cm/ hr in primi <2cm / hr in multi Arrest( failure of descent): No progress of descent for <2 hour

37. Management of 2 nd stage of labour Assesment : Evaluation of uterine activity Evaluation of maternal expulsive effort FHR status every 5 min Fetal position, clinical pelvimetry Re- estimation of fetal weight Management: Increasing or initiating oxytocin to improve maternal expulsive effort Instrumental or operative vaginal delivery or CS

38. Labour following cesarean section In women undergoing a trial of labor following cesarean section, the partographic zone 2-3 h after the alert line represents a time of high risk of scar rupture. An action line in this time zone would probably help reduce the rupture rate without an unacceptable increase in the rate of cesarean section

39. references DC Dutta’s textbook of Obstetrics, 9 th edition Williams textbook of Obstetrics 25 th edition The partograph (who)