PLOTTING A PARTOGRAPH

Dr Sunita Singal

AimsAims

To understand the use of the To understand the use of the partographpartograph

Practice using the partographPractice using the partograph

To recognise slow progress in labour To recognise slow progress in labour and manage it appropriatelyand manage it appropriately

Partograph:Partograph:

a graphical record of progress in laboura graphical record of progress in labour

Should be used for all deliveriesShould be used for all deliveries

Start using once the woman is in labourStart using once the woman is in labour

LabourLabour

A correct diagnosis of labour has to be A correct diagnosis of labour has to be made before opening the partographmade before opening the partograph

2-3 uterine contractions in 10mins2-3 uterine contractions in 10mins Progressive shortening and thinning of the Progressive shortening and thinning of the

cervix during labour andcervix during labour and Cervical dilatation Cervical dilatation 4cm4cm or more dilated: or more dilated:

openopen partograph partograph

Monitoring of first stage of labourMonitoring of first stage of labour

In Latent PhaseAfter 8 hours

Contractions stronger, more frequent, no change in dilatation or effacement ROM +/-

REFER to FRU

Prolonged latent phase

No increase in intensity / frequency / duration of contractions, membranes not ruptured and no progress in cervical dilatation

Ask woman to relax

Beware of false labourBeware of false labour

Regular pains, but no progressive cervical dilatationRegular pains, but no progressive cervical dilatation Consider causes ? UTI, ? BV, ? infectionConsider causes ? UTI, ? BV, ? infection ? Prolonged latent phase? Prolonged latent phase

Contractions persist mild-moderateContractions persist mild-moderate At termAt term CX less than 3cmCX less than 3cm Membranes intactMembranes intact

BEWARE strong contractions without progress, check BEWARE strong contractions without progress, check lie, presentation- act fast- REFERlie, presentation- act fast- REFER

True labour pains False labour pains

Regular and predictable Irregular

Felt first in lower back & sweeps towards lower abdomen

Remains confined to lower abdomen

Not relieved by rest Often relieved by rest

Increase in duration , intensity and frequency with time

Does not increase in duration, intensity or frequency

“Show” present “Show” absent

Accompanied by cervical changes

Not accompanied by cervical changes

Modified Modified WHO WHO PartographPartograph

Filling a Partograph

• Identification data– Name– Age,– Parity, – Date and time of

admission– Registration number;– Time of rupture of

membranes.

Fetal monitoringFetal monitoring

Fetal monitoring

LIQOUR

I Membranes intact

C Clear liqour

M Meconium stained liqour

B Blood stained liqour

MOULDING

+ sutures apposed

++ sutured overlapped, reducible

+++ sutures overlapped, irreducible

Plotting a partographPlotting a partograph

Interventions– Mention dose, route and

time of administration of any drug

– Mention the food items and liquids consumed

Maternal vital signs

Progress in labourProgress in labour Regular contractionsRegular contractions < 20 sec,< 20 sec, 20-40 sec,20-40 sec, > 40 sec> 40 sec

Dilatation of cervix –at least 1cm per hour Dilatation of cervix –at least 1cm per hour (follows alert line)(follows alert line)

- - chart aschart as XX

Descent of presenting part in fifths Descent of presenting part in fifths paplablepaplable

- - chart aschart as OO

Plotting a partographPlotting a partograph

Labor• Begin plotting in active labor• Cervical dilatation > 4 cms• Repeat P/V after 4 hours and plot the cervical dilatation

Progress of Labor

ALERT and ACTION linesALERT and ACTION lines

• 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.

• Moving to the right or the alert line may require referral to hospital for extra vigilance

• Action line: Parallel and 4 hours to the right of the alert line. A lag time of 4 hours between a slowing of labour and the need for intervention.

• When Action line is reached this is the critical line at which specific management decisions must be made

Note that the first plot Note that the first plot on the partograph on the partograph

starts on the Alert Linestarts on the Alert Line

xx

o o

Slow Slow progress progress in labourin labour

Between alert and action linesBetween alert and action lines

• At lower level facility, the women must be transferred to At lower level facility, the women must be transferred to a higher level facility which can do a cesarean section, a higher level facility which can do a cesarean section, unless the cervix is almost fully dilatedunless the cervix is almost fully dilated

• Continue routine observations but prepare for transfer if Continue routine observations but prepare for transfer if neededneeded

• ARM may be performed if membranes are still intactARM may be performed if membranes are still intact

Crossing the Action line

• Crossing of the Action line (the plotting moves to the right of the Action line) : indicates the need for intervention

• By the time the action line is crossed the woman should ideally have reached the FRU for the appropriate intervention to take place

At or beyond action line:InterventionAt or beyond action line:Intervention

• Repeat full medical assessmentRepeat full medical assessment• Consider intravenous infusion / bladder catheterization / Consider intravenous infusion / bladder catheterization /

analgesiaanalgesia• OptionsOptions Augment with oxytocin by intravenous infusion only if there are Augment with oxytocin by intravenous infusion only if there are

no contraindicationsno contraindications Refer to a higher level facility Refer to a higher level facility Deliver by cesarean section if there is fetal distress or Deliver by cesarean section if there is fetal distress or

diagnosis is obstructed labourdiagnosis is obstructed labour

Slow progress in labour ?Slow progress in labour ?

PowersPowers Inadequate contractions (dysfunctional labour)Inadequate contractions (dysfunctional labour)

PassagePassage Pelvis too small for baby (cephalopelvic disproportion Pelvis too small for baby (cephalopelvic disproportion

– CPD)– CPD)

PassengerPassenger Abnormal presentation or position ( e.g. transverse)Abnormal presentation or position ( e.g. transverse) Fetal abnormality (e.g. hydrocephalus)Fetal abnormality (e.g. hydrocephalus)

PowersPowers

Slow progress often due to inadequate uterine Slow progress often due to inadequate uterine contractionscontractions

Restore normal progress by:Restore normal progress by:- rupturing membranes rupturing membranes - giving syntocinon by IV infusion where allowedgiving syntocinon by IV infusion where allowed- consider referral to FRUconsider referral to FRU

Reassess in 2 hoursReassess in 2 hours If no further progress REFER for CSIf no further progress REFER for CS

Cephalopelvic disproportion (CPD)Cephalopelvic disproportion (CPD)

Malpresentation or MalpositionMalpresentation or Malposition

Fetal abnormalityFetal abnormality

Passage or Passenger:Passage or Passenger:

Remember!Remember!

Slow progress may be due to any of the Slow progress may be due to any of the 3Ps3Ps

Augmentation with syntocinon may be Augmentation with syntocinon may be dangerous and cause rupture of uterusdangerous and cause rupture of uterus

Slow progress in second stage:Slow progress in second stage:

Delay in descent of presenting partDelay in descent of presenting part

Delay in expulsionDelay in expulsion

Slow progress in second Slow progress in second stage: Managementstage: Management

Review maternal positionReview maternal position Consider augmentationConsider augmentation If fetal head >2/5 palpable deliver by CS If fetal head >2/5 palpable deliver by CS

(Refer)(Refer) If fetal head < 1/5 palpable assist delivery If fetal head < 1/5 palpable assist delivery

by vacuum extraction (if avaliable)by vacuum extraction (if avaliable)

If If slowslow progress becomes progress becomes nono progress and no action is progress and no action is

taken labour becomes taken labour becomes obstructedobstructed.

RECAPRECAPWhen to start the partographWhen to start the partograph

Correct diagnosis of labourCorrect diagnosis of labour

Diagnosis and management of slow Diagnosis and management of slow progress in labour and ensure timely progress in labour and ensure timely referralreferral

Diagnosis of obstructed labourDiagnosis of obstructed labour