Practical partography


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Practical partography

  1. 1. PRACTICAL PARTOGRAPHY Assoc Prof Dr Hanifullah Khan
  2. 2. Partograph • A graphical record of labour • Purpose – To chart the progress of labour – To chart important events during labour – To chart maternal & fetal condition • WHO developed
  3. 3. Why do we need one?• For early detection of abnormal progress of labour• Recognition of CPD• Can allow time & discussion of further management of labour• Make observations & recording of fetomaternal condition more objective• Prevention of fetomaternal problems & complications
  4. 4. Components of the partograph • Can be divided into 3 parts – Part I : fetal condition ( at top ) – Part II : progress of labour ( middle ) – Part III : maternal condition (bottom )
  6. 6. Overviewo This part of the graph is used to monitor the fetuso Fetal well-being is assessed via charting of o Fetal heart rate o membranes and liquor o moulding the fetal skull bones
  7. 7. Fetal chartingFetal heart Membranes & LiquorBasal fetal heart rate • intact membranes … I• brady>110-160<tachy • ruptured membranesDecelerations? yes/no • + clear liquor …….. CRelation to contractions? • ruptured membranes +  Early meconium liquor … M  Variable • ruptured membranes +  Late bloody liquor …….. B • ruptured membranes + no liquor………….. A
  8. 8. Moulding • The fetal skull is made up by a number of bones divided by sutures • These bones only fuse after birth • This is to allow the bones to overlap during delivery – Decrease the diameter • The overlap of the bones is termed moulding • In short, moulding allows the pelvis to accommodate the fetal head
  9. 9. Moulding on the Partogram• Increasing moulding suggests cephalopelvic disproportion (CPD)• Marking on the partogram is as follows: Extent of moulding as marked on Partogram separated bones, sutures felt easily 0 bones just touching each other + overlapping bones, reducible ++ severely overlapping bones, non-reducible +++
  10. 10. Charting fetal well-beingNote the progressive bradycardia, liquor change & worseningmoulding
  12. 12. ComponentsCervicaldilatationDescentof headTime The main feature of this section is the graph of cervical dilatation against timeContractions Note the division between latent & active phases
  13. 13. Phases of labour• Labour is not a continuous process – Begins slowly & becomes faster with time • Important to recognize this fact – Measured objectively from 0-10 cm cervical dilatation – This is Stage I• Initial slow part is termed the latent phase – Coincides with the taking up & effacement of the Cx – Objectively, from 0 to 4 cm cervical dilatation• The faster part is active labour – This is all about cervical dilatation – From 4 -10 cm dilatation
  14. 14. Cervical dilatation• One way of assessing progress of labour• The firm & long Cx becomes soft & shorter towards term• The important dilatation is with reference to the internal os• Dilatation in concert with contractions denotes labour
  15. 15. Charting dilatation• The vaginal examination will decide if the patient is in the active or latent phase• In the active phase of labour , recording of cervical dilatation starts on the alert line • The alert line drawn from 4 cm dilatation represents the rate of 1cm/hour• The action line is drawn 4 hrs to the right of the alert • If she is in latent phase, charting is done from the line and parallel to it beginning (0 time) – This is the critical line at – when the active phase of which specific management labor begins, recording is decisions must be made transferred to the alert line – In normal labour, plotting of cervical diltation remains on the alert line or to left of it
  16. 16. From latent to active phase• If the pt passes from latent to active phase in < 8 hours – transfer plotting of cervical dilatation to the alert line using the letters TR• Leave the area between the transferred recording blank. – The broken transfer line is not part of the process of labor • If she is in latent phase,• Do not forget to transfer all charting is done from the other findings vertically beginning (0 time) – when the active phase of labor begins, recording is transferred to the alert line
  17. 17. • when a woman ,s partograph reaches the action line , she must be carefully reassessed to determine why there is lack of progress , and a decision must be made on further management ( usually by an obesterician or resident )• when a woman in labor passes the latent phase in less than 8 hours i.e., transfers from latent to active phase , the most important feature is to transfer plotting of cervical diltation to the alert line using the letters TR,• Leaving the area between the transferred recording blank. The broken transfer line is not part of the process of labor• do not forget to transfer all other findings vertically
  18. 18. Descent of the fetal head• Assessed abdominally• Using the rule of fifth to assess engagement – Assess how much of the head is still felt per abdomen• When only 2/5 or less of the fetal head palpated above the level of symphysis pubis , this implies the head is engaged – The vertex has passed or is at the level of ischial spines
  19. 19. Station• Assessing descent of the fetal head by vaginal examination• The ischial spines are the reference point• In cephalic presentation, the Vertex is used to assess progress• Station 0 – level of the spines This is the most important indicator of progress
  20. 20. PositionThe vertex presentation is further classified according to the positionof the occiput
  21. 21. Charting Dilatation & Descent Crossing the action line diltation of the cervix is plotted with No descent Dilatation an X , arrested desent of the fetal head is plotted with an O uterine contractions are plotted with Note the time differential shading
  22. 22. Uterine contractions• Uterine contractions should increase progressively• Effect of the pressure of the head on the upper vagina (Ferguson reflex)• The frequency, duration & intensity are recorded• May be recorded as the no. of contractions/10 min• Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase
  23. 23. Charting Uterine contractions • Measured in seconds from the time the contraction is first felt abdominally , to the time the contraction phases off • Each square represents one contraction • Correlation with oxytocin use important Palpate number ofcontraction in 10 minutes & duration of each contraction in seconds Between 20 & > 40 seconds 40 s
  25. 25. Note the components Drugs e.g.opiates/oxytocics Vital signs Urine monitoring
  27. 27. Prolonged latent phase• A prolonged latent phase may denote problems & require attention• A heavy line is drawn on the partograph at the end of 8 hours of the latent phase
  28. 28. Polonged Active phase• Movement of the dilatation charting beyond the alert line may denote obstruction• Do not just focus on the dilatation alone• Other aspects such as descent, fetal heart rate, liquor character & moulding must be taken together
  29. 29. Secondary arrest of cervical diltation • This may denote midcavity or outlet obstruction
  30. 30. Secondary arrest of head descant• Another example
  31. 31. Important points• It is important to realize that the partograph is a tool for managing labor progress only• It does not help to identify other risk factors that may have been present before labor started• Charting is only done when the pt is in labour
  32. 32. Diagnosis of labourRegular painful contractions resulting in progressive change of the cervix +/- show +/- rupture of membranes Does not denote labour!