Partograph and labor dystocia for undergraduate

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undergraduate course lectures in ob&gyne prepared by DR Manal Behery.Professor of OB&GYNE.Faculty of medicine,ZAGAZIG University

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  • Successful completion of a pregnancy requires the harmonious functioning of the critical factors in labor. When this does not occur, it is noted as a dysfunctional labor.
  • d. What interventions might the nurse implement?
  • Define the term cephalopelvic disproportion (CPD):
    a. What are the causes of CPD?
    b. What are the symptoms for CPD in the laboring woman?
    c. What is the medical treatment for CPD?
  • Partograph and labor dystocia for undergraduate

    1. 1. PartographPartograph
    2. 2. PartographPartograph  A partograph is a graphical  record of the observations made  of a women in labor  For progress of labor and conditions of the mother and  the fetus
    3. 3. History Of PartogramHistory Of Partogram Friedman's partogram  Cervical dilatation and fetal station against time in hours from onset of labour.yielded the typical sigmoid or 'S' shaped curve
    4. 4. ObjectivesObjectives  early detection of abnormal progress of a labour prevention of prolonged labour  Recognize cephalo pelvic disproportion long before obstructed labour Assist in early decision on transfer , augmentation , or termination of labour Early recognition of maternal or fetal problems
    5. 5. Components of the partographComponents of the partograph Part 1 : fetal condition ( at top ) Part 2 : progress of labour ( at middle ) Part 3 : maternal condition ( at bottom )
    6. 6. Mother information Fetal well-being • Fetal heart rate • Character of liquor • Moulding Labour progress • Dilatation • Descent • Uterine contraction Medications • Oxytocin • Pain relief (e.g. pethidine) Maternal well-being • BP, Pulse, Temperature • Urine – albumin, glucose, acetone • Urine output
    7. 7. Part 1 : Fetal conditionPart 1 : Fetal condition Recording fetal heart rateRecording fetal heart rate
    8. 8. Membranes and liquorMembranes and liquor Dilated cervix with bag of fore water I: intact C : clear M : muconium B : blood stained
    9. 9. Molding the fetal skull bonesMolding the fetal skull bones  . Increasing molding with the head high in the pelvis is an ominous sign of Cephalopelvic disproportion.  separated bones . sutures felt easily……….O  bones just touching each other……………..+  overlapping bones …………… …………...++  severely overlapping bones ( notable ) ……..+++
    10. 10. Part 2 – progress of labourPart 2 – progress of labour . Cervical dilatation: it is divided into a latent phase and an active phase  Descent of the fetal head  Uterine contractions
    11. 11. Cervical dilatationCervical dilatation  It is the surest way to assess progress of labour
    12. 12. latent phaselatent phase  Starts from onset of labour until the cervix reaches 3 cm dilatation  lasts 8 hours or less  Contractions at least 2/10 min contractions  each lasting < 20 seconds
    13. 13. Active phase :Active phase :  The cervix should dilate at a rate of 1 cm / hour or faster  Contractions at least 3 / 10 min each lasting < 40 seconds
    14. 14. Alert line ( health facility line )Alert line ( health facility line ) The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm / hour Moving to the right or the alert line means referral to hospital for extra care
    15. 15. Action line ( hospital line )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 line at which specific management decisions must be made at the hospital
    16. 16.  When labor goes from latent to active phase , plotting of the dilatation is immediately transferred from the latent phase area to the alert line
    17. 17. Abnormal labor progressAbnormal labor progress
    18. 18. Descent of the fetal headDescent of the fetal head  The rule of fifth BY abdominal examination
    19. 19. Assessing descent of the fetal PV;Assessing descent of the fetal PV; 0 station is at the level of the ischial spine0 station is at the level of the ischial spine
    20. 20. Recording uterine contractionRecording uterine contraction
    21. 21. PART 3:Recording of maternalPART 3:Recording of maternal conditioncondition
    22. 22. -- 
    23. 23. Abnormal labor and DystociaAbnormal labor and Dystocia One of the main functions of the partograph is to detect early deviation from normal progress of labor
    24. 24. 0 2 4 6 8 10 12 2 4 6 8 10 12 14 16 Latent phase Active phase 2nd stage1st stage max slope acceleration dec Time (hours) Cervical dilatation (cm) Friedman labor curve in nulliparous
    25. 25. Normal progress in laborNormal progress in labor
    26. 26. A prolonged latent phase B prolonged active phase C arrest active phase Abnormal progress in labor
    27. 27. Prolonged latent phaseProlonged latent phase 􀁺 Nulliparas Multiparas prolonged >20 hr > 14 hr Normal average 6.4 hr 4.8 hr
    28. 28. ManagementManagement Prolong Latent PhaseProlong Latent Phase – Simple analgesia – Encourage mobilizati on – Reassurance – ARM and oxytocin will cause poor progress later
    29. 29. Protraction disordersProtraction disorders 􀁺 Nulliparas Multiparas Descent <1.0 cm/h <2.0 cm/h Dilation <1.2 cm/h <1.5 cm/h Average 8hr 5hr
    30. 30. Arrest disorderArrest disorder 􀁺 Nulliparas Multiparas Descent >2h >1h Dilation >2h >1h
    31. 31. Causes of Protraction disordersCauses of Protraction disorders 􀁺 minor malpositions such as occiput posterior. improperly administered conduction anesthesia. ,excessive sedation. Fetopelvic disproportion.
    32. 32. Treatment of protraction andTreatment of protraction and arrest disorderarrest disorder Cesarean section is indicated in the presence of confirmed fetopelvic disproportion. In the absence of fetopelvic disproportion, support and close observation oxytocin augmentation
    33. 33. Critical Factors Psyche Powers Passenger Passageway Dysfunctional Labor is related to Abnormalities of the Critical Factors:
    34. 34. Psychology of birthPsychology of birth The progress of labor and birth can be adversely affected maternal fear and tension. Norepinephrine and epinephrine may stimulate both alpha and beta receptors of the myometrium and interfere with the rhythmic nature of labor. Anxiety can also increase pain perception and lead to an increased need for analgesia & anesthesia.
    35. 35. Characteristics of theCharacteristics of the powerpower  Intensity is greater in the fundus  Average 24mmHg  Well synchronized  Frequency  Duration 60s  regular  Rhythm and force  Basal resting pressure 12-15mmHg
    36. 36. Fetal monitoringFetal monitoring
    37. 37. Friedman’s GraphFriedman’s Graph Hypotonic Uterine ContractionsHypotonic Uterine Contractions Prolonged active phase Normal Curve
    38. 38. Therapeutic InterventionsTherapeutic Interventions – Ambulation – Nipple Stimulation --release of endogenous Pitocin – Enema--warmth of enema may stimulate contractions – Amniotomy--artificial rupture of the membranes – Augmentation of labor with Pitocin
    39. 39. AmniotomyAmniotomy  Amniotomy is the artificial rupture of the amniotic sac with a tool called the amniohook  # 1-Check the fetal heart tones – Assess color, odor, amount – Provide with perineal care – Monitor contractions – Check temperature every 2 hours
    40. 40. Hypertonic and uncoordinatedHypertonic and uncoordinated dysfunctiondysfunction Resting tone Dyssynchronous Frequent intense contraction Constriction ring Tocolysis Decrease oxytocin Cesarean section Sedation
    41. 41. Friedman’s GraphFriedman’s Graph Hypertonic Uterine ContractionsHypertonic Uterine Contractions Prolonged latent phase
    42. 42. Cephalopelvic Disportion (CPD)Cephalopelvic Disportion (CPD) Causes – Large baby or small pelvis – Usually diagnosed when there is an arrest in descent Symptoms – Station remains the same does not descend Treatment – Usually do a cesarean delivery if cause is pelvis – Utilize other measures such as forceps, vacuum extraction, episiotomy.
    43. 43. Pelvi- Latin word pelvis (basin) Metron - Greek word for measure Pelvimetry means to measure the pelvis.
    44. 44. Three level of bony pelvisThree level of bony pelvis
    45. 45. Measuring diagonal conjugate  Insert two fingers into the vagina until they reach the sacral promontory. The distance from the sacral promontory to the exterior portion of the symphysis is the diagonal conjugate and should be greater than 11.5 cm.  Unengaged fetal head
    46. 46. • Feel the ischial spines for their relative prominence or flatness. • Ischial prominence narrows the transverse diameter of the pelvis. • Feel the pelvic sidewalls to determine whether they are parallel (OK), diverging (even better), or converging (bad). • Narrow sacrosciatic notch
    47. 47.  Measure the bony outlet by pressing your closed fist against the perineum. Greater than 8 cm bituberous ( or transverse outlet) is considered normal. Narrow pubic arch<90

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