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Partograph dr sunita
 

Partograph dr sunita

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  • Regular, painful and progressive contractions
  • Mention frequency and responsibility, doctors and midwives
  • Ventouse preferred to forceps, and symphysiotomy may not be practised in some countries by law ie Ghana

Partograph dr sunita Partograph dr sunita Presentation Transcript

  • PLOTTING A PARTOGRAPHDr Sunita Singal
  • AimsAims To understand the use of theTo understand the use of thepartographpartograph Practice using the partographPractice using the partograph To recognise slow progress in labourTo recognise slow progress in labourand 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 beA correct diagnosis of labour has to bemade before opening the partographmade before opening the partograph 2-3 uterine contractions in 10mins2-3 uterine contractions in 10mins Progressive shortening and thinning of theProgressive shortening and thinning of thecervix during labour andcervix during labour and Cervical dilatationCervical dilatation 4cm4cm or more dilated:or more dilated:openopen partographpartograph
  • Monitoring of first stage of labourMonitoring of first stage of labourIn Latent PhaseAfter 8 hoursContractions stronger, morefrequent, no change indilatation or effacementROM +/-REFER to FRUProlonged latent phaseNo increase in intensity /frequency / duration ofcontractions, membranesnot ruptured and noprogress in cervicaldilatationAsk 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, checkBEWARE strong contractions without progress, checklie, presentation- act fast- REFERlie, presentation- act fast- REFER
  • True labour pains False labour painsRegular and predictable IrregularFelt first in lower back & sweepstowards lower abdomenRemains confined tolower abdomenNot relieved by rest Often relieved by restIncrease in duration , intensityand frequency with timeDoes not increase induration, intensity orfrequency“Show” present “Show” absentAccompanied by cervicalchangesNot accompanied bycervical changes
  • ModifiedModifiedWHOWHOPartographPartograph
  • Filling a Partograph• Identification data– Name– Age,– Parity,– Date and time ofadmission– Registration number;– Time of rupture ofmembranes.
  • Fetal monitoringFetal monitoring
  • Fetal monitoring
  • LIQOURI Membranes intactC Clear liqourM Meconium stained liqourB Blood stained liqourMOULDING+ sutures apposed++ sutured overlapped, reducible+++ sutures overlapped, irreducible
  • Plotting a partographPlotting a partographInterventions– Mention dose, route andtime of administration ofany drug– Mention the food items andliquids 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 hourDilatation of cervix –at least 1cm per hour(follows alert line)(follows alert line)-- chart aschart as XX Descent of presenting part in fifthsDescent of presenting part in fifthspaplablepaplable-- chart aschart as OO
  • Plotting a partographPlotting a partographLabor• 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 tothe point of expected full dilatation at the rate of 1 cm perhour.• Moving to the right or the alert line may require referral tohospital for extra vigilance• Action line: Parallel and 4 hours to the right of the alertline. A lag time of 4 hours between a slowing of labourand the need for intervention.• When Action line is reached this is the critical line atwhich specific management decisions must be made
  • Note that the first plotNote that the first ploton the partographon the partographstarts on the Alert Linestarts on the Alert Line
  • xxo oSlowSlowprogressprogressin labourin labour
  • Between alert and action linesBetween alert and action lines• At lower level facility, the women must be transferred toAt lower level facility, the women must be transferred toa 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 ifContinue routine observations but prepare for transfer ifneededneeded• 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 plottingmoves to the right of the Action line) :indicates the need for intervention• By the time the action line is crossed thewoman should ideally have reached the FRUfor 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 areAugment with oxytocin by intravenous infusion only if there areno contraindicationsno contraindications Refer to a higher level facilityRefer to a higher level facility Deliver by cesarean section if there is fetal distress orDeliver by cesarean section if there is fetal distress ordiagnosis 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 disproportionPelvis 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 uterineSlow progress often due to inadequate uterinecontractionscontractions Restore normal progress by:Restore normal progress by:- rupturing membranesrupturing 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 abnormalityPassage or Passenger:Passage or Passenger:
  • Remember!Remember! Slow progress may be due to any of theSlow progress may be due to any of the 3Ps3Ps Augmentation with syntocinon may beAugmentation with syntocinon may bedangerous 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 secondSlow progress in secondstage: Managementstage: Management Review maternal positionReview maternal position Consider augmentationConsider augmentation If fetal head >2/5 palpable deliver by CSIf fetal head >2/5 palpable deliver by CS(Refer)(Refer) If fetal head < 1/5 palpable assist deliveryIf fetal head < 1/5 palpable assist deliveryby vacuum extraction (if avaliable)by vacuum extraction (if avaliable)
  • IfIf slowslow progress becomesprogress becomes nonoprogress and no action isprogress and no action istaken labour becomestaken labour becomesobstructedobstructed.
  • RECAPRECAPWhen to start the partographWhen to start the partographCorrect diagnosis of labourCorrect diagnosis of labour Diagnosis and management of slowDiagnosis and management of slowprogress in labour and ensure timelyprogress in labour and ensure timelyreferralreferralDiagnosis of obstructed labourDiagnosis of obstructed labour