Partogram
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Partogram

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Partogram Partogram Document Transcript

  • The Partogram Dr. C. Savona-Ventura MD, DScMed, FRCOG, Accr.Cert.OG, MRCP The Partogram• A graphic representation of the progress of labour – Cervicograph – Descent of Head [cf moulding] – Uterine contractions – Features that assist progress [membranes/augmentation/drugs] – Maternal condition [heart rate, BP, urinalysis] – Fetal condition [heart rate, liquor] 1
  • Phases in progress of Labour• LATENT PHASE:- » Nullipara Multipara » 8.6-20.6 hrs 5.3-13.6 hrs• ACTIVE PHASE:- – Acceleration Phase ] 4.9-11.7 hrs 2.2-5.2 hrs – Phase of Maximum Slope ] – Deceleration Phase 54 min-3.3 hrs 14 -53 min• SECOND STAGE 57 min-2.5 hrs 18 -50 min• THIRD STAGE up to 20 min Labour progress - cervical dilatation 10 2nd Stage 8 1st Stage of Labour 6 LATENT 1 cm/hr 4 PHASE ACTIVE 2 PHASE 0 0 5 10 15 20 2
  • Latent Phase• Poor rate of cervical dilatation but general preparation of cervix.• Duration: Nullipara Multipara » 8.6-20.6 hrs 5.3-13.6 hrs• Assessed using Bishop Score 0 1 2 3 – Cervical dilatation 0 1-2 3-4 5-6+ – Cervical effacement [%] 0-40 40-60 60-80 80+ [cm] 3 2 1 0 – Cervical position Post Mid Ant – Cervical consistency Firm Mod Soft – Station re ischial spine [cm] -3 -2 -1,0 +1,+2• The use of the partogram during the latent phase not of use since this would chart only cervical dilatation. We should use a cervicograph. Prolonged Latent Phase • Definition – >20 hrs [nullipara]; >14 hrs [multipara] • Aetiology – Excessive sedation – Unfavourable Cervix – Idiopathic [forced induction] – False Labour • Outcome – 14% will go into a Protracted Active Phase 3
  • Prolonged Latent Phase• Management DIAGNOSIS EVALUATE CAUSE THERAPEUTIC REST No Change Membranes ruptured Membranes Intact Progress to Active Phase Augmentation False Labour Active Phase• Good rate of cervical dilatation; cervix fully effaced.• Rate: Nullipara Multipara Lower limit of Normal » ~3.0 cm/hr ~5.7 cm/hr ~1.0 cm/hr• The use of the partogram during the active phase is essential for good intrapartum management• Draw ALERT & ACTION LINES at onset of active phase – At 2-3 cm dilatation with patient getting strong and regular contractions. Slope at 1cm/hr; lines four hours apart 4
  • Partogram - cervical dilatation 10 9 CERVICAL DILATATION 8 7 6 5 4 3 2 1 ALERT LINE 0 TIME ACTION LINE Uterine contractions• Aim at:- strong & regular contractions• ASSESS DURATION OF CONTRACTION – mild moderate strong – <20 sec 20-40 sec >40 sec• ASSESS FREQUENCY OF CONTRATIONS – Number of contractions in last 10 min of each ½ hr. – increased frequency from 1:10 to 5:10 minutes 5
  • Descent of head in fifths per abdomen • Engagement at 2/5 and less • If 3/5 or more than CPD [absolute or relative] is presentVaginal assessment inrelation to ischial spines notuseful to define engagementsince position of spinesdependant on type of pelvis. Prolonged Active Phase• Definition – >6 hrs or >1.2 cm/hr [nullipara]; >5.2 hrs or >1.5 cm/hr [multipara]• Aetiology – CephaloPelvic Disproportion [often relative] – Fetal head malposition: OP/OT – Idiopathic [early ARM] – Excessive sedation• Outcome – 39% Po & 13% P1+ will go into Secondary Arrest 6
  • Prolonged Active Phase 10 9 CERVICAL DILATATION 8 7 6 5 4 3 2 ALERT LINE 1 NORM AL 0 DYSFUNCTIONAL TIME ACTION LINE Prolonged Active Phase• Management DIAGNOSIS EVALUATE CAUSE HYPOTONIA HYPERTONIA Augment Augmented? CPD Normal Progress Reduce Dose LSCS Vaginal Delivery 2o Arrest 7
  • Secondary Arrest of Active Phase• Definition – No change in cervical dilatation over a period of 2hrs+. Cervix becomes oedematous. Can occur at 4-7 cm dilatation or as a protracted Deceleration phase• Aetiology – CephaloPelvic Disproportion [often absolute] – Fetal head malposition [OP/OT] or Malpresentation [breech] – Insufficient uterine action – Excessive sedation• Outcome – Will require LSCS. If protracted deceleration beware of shoulder impaction Partogram - cervical dilatation 10 9 CERVICAL DILATATION 8 7 6 5 4 3 2 ALERT LINE 1 NORM AL 0 2 ARREST PROTRACTED TIME ACTION LINE 8
  • Secondary Arrest of Active Phase• Management DIAGNOSIS EVALUATE CAUSE No CPD head 2/5- CPD head 3/5+ Assess Uterine Activity Optimal Sub-Optimal head 2/5 Augment LSCS No Response Good Response Vaginal Delivery 9