2. OUTLINE OF PRESNTATION
Introduction
Methods of labor progress documentation &
monitoring
Advantages of labour monitoring using a Partograph
History, components and of steps in documenting
findings on the partograph
Indicators of labor progress on the partograph
Sample partograph
2
3. OUTLINE...
Definition of abnormal labor (dystocia)
Summary of normal labor
Friedman’s normal labor pattern curve
Incidence and etiologies(risk factors) of abnormal
labor
Classifications & diagnosis of abnormal labor
Management options of abnormal labor patterns
3
4. INTRODUCTION
Each year >1/2 a million MD occur world wide
~ 99% of these deaths developing countries
Significant proportion of these deaths follow
prolonged labour (PL)
PL occurs mainly due to CPD & it results in:
1. OL
2. Uterine rupture
3. Obstetrics fistula &
4. Less directly in:
a. PPH &
b. Neonatal infection
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6. RECORDING OF LABOR EVALUATIONS & IT’S
PROGRESS :
Helps in early detection of abnormal labor &
prevention of prolonged labour:
► ↓Maternal & PN M & M.
Two methods:
1. Chart documentation
Findings from the evaluation of the patient are periodically documented on her chart
2. Partographic Monitoring of labor
Documenting labor progress, maternal & fetal status on the partograph
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7. RECORDING OF LABOR EVALUATIONS &
PROGRESS...
It is the graphic recording of the progress of
labour and the condition of the mother and
the fetus
It serves as an “early warning system” and
assists in early decision to:
Transfer,
Augmentation &
Termination of labour
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8. ADVANTAGES OF PARTOGRAPH
I. Pictorial display of events of labor, thus
1. Clarifies recordings
2. Avoids lengthy written notes
3. Facilitates recognition of any omissions
4. Saves time → Companionship
II. Considerable educational value
All interrelated variables of labor can be seen on a single paper
III. Low cost, feasible
IV. Easy documentation of findings
V. Quick evaluation of findings
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9. ADVANTAGES OF PARTOGRAPH...
Easy handing over of many laboring mothers
Can be easily understood by midlevel health
workers ( clear & easy indicators for referral)
Suitable for research purposes
Clear landmarks to assess when labor progress is
delayed( alert and action lines)
Prevention of prolonged labor
Avoids unnecessary use of augmentation
Improves out come of labor →↑Credibility of
formal health sector
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11. HISTORY OF PARTOGRAPH
In 1954 E. A. Freidman, following a study in a large
number of women in USA described a normal Cx dilation
First to show plotting Cx dilation Vs time
His work has been a foundation on which others built...
He divided labour functionally into:
1. Early (latent phase)
Extends over 8-10hrs
Up to 3cm Cx dilation
2. Active phase
Characterized by acceleration from about 3-10cm at the end of which deceleration occurs
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13. HISTORY OF PARTOGRAPH...
The WHO partograph (1987)
Safe motherhood conference in 1987 “A call to action”
The health workers involved in the care of mothers &
children take positive action to reduce M M & M.
“All pregnant women in labor are managed by:
o Appropriately trained personnel using practical & relevant technology”
One of which is the partograph
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15. THE WHO PARTOGRAPH...
Principles:
1. The active phase commences at 3 cm cx dilation
2. The latent phase should not last >8 hrs
3. During active phase, the rate of Cx dilation
shouldn't be <1cm/hr
4. Vx examination
Infrequently as compatible with safe practice (Q 4 hrs is recommended)
5. Health personnel managing labor may have difficulty
in constructing alert & action line ►pre-drawn lines
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16. THE WHO PARTOGRAPH...
It has been modified to make it
simpler & easier to use(2001)
The latent phase has been removed &
plotting begins in the active phase
when the cx is 4 cm dilated
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19. USE OF THE PARTOGRAPH
Partograph is used for the assessment of:
Fetal well being
Maternal well being
Progress of labor
USING THE PARTOGRAPH
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20. PARTS OF WHO PARTOGRAPH
It has four Parts:
1. Patient information
2. Fetal condition
3. Progress of labour
4. Maternal condition
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21. COMPONENTS OF PARTOGRAPH
Section Component Instructions for
filling:
I. Patient
informations
o Identification Name
Hospital number
Date & time of
admission
o Reproductive
Performance
Gravidity
Parity
o Membrane
condition
Time of rupture
of membranes
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22. COMPONENTS...
Section Component Instructions for filling:
II.Fetal
1. FHR
o Count Q 30’
Indicated with a dot ()
2. Liquor
o Color of AF at
Q V/E
I- Intact membranes;
C- clear liquor;
M- meconium stained
B-Blood stained
3. Molding
o Degree of
molding at Q
V/E
0,
+1(apposed),
+2( reducible overlap),
+3 ( irreducible overlap)
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23. LABOUR PROGRESS…
Alert line:
A line starts @ 4 cm of cervical dilatation to the point
of expected full dilatation @ the rate of 1 cm/hour.
Action line:
Parallel & 4 hrs to the right of the alert line.
Hours:
Refers to the time elapsed since onset of active phase
of labour (observed or extrapolated).
Time:
Record actual time.
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24. COMPONENTS...
Section Component Instructions for filling:
III.Labor
progress
1. Cervical
dilatation
o Assessed @
Q V/E
Indicated by - ‘X’
Start plotting on the action line
At Cx dilataion of ≥4 cms (in
active phase of 1st stage of
labour)
2. Descent
o Assessed @
Q V/E
Indicated by ‘o’
It is the a measure of fetal
head palpable above symphysis
pubis Slide 73
3. Uterine
contractions
Number,
Intensity &
Duration Uterine Contractions...
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26. COMPONENTS...
Section Component Instructions for filling:
IV.Mat.
Cond.
1. Vital signs BP indicate by – “” & record
Q 4 hrs
PR indicate by – “” & record Q
30’
Tempratre in °C& record Q 2
hrs
2. Urine output Protein, acetone & volume
Record Q time urine is passed.
3. Medications Oxytocin:
Amount per volume IV
fluids in dpm Q30’
Drugs given: Any additional
drugs given. 26
27. STEPS IN FILLING THE
PARTOGRAPH
STEP DESCRIPTION
1 Cervical dilatation-
@ dilatation of ≥ 4 cms,
Start plotting on the action line
Mark with “X”
2 Time
On the same vertical line as the cervical dilatation
3 Descent- filled on the same vertical line as the cervical
dilatation
5th of fetal head palpable above the symphysis pubis
Mark with “O”
4 Uterine contractions-
Filled by covering the number of vertical squres corresponding to
the number of contractions; 27
28. STEPS...
Step Description
5 Fetal condition
On the same vertical line as the cervical dilatation
6 Maternal condition
Filled on the same vertical line as the cervical
dilatation
7 Repeat evaluation:
performed and filled four hours later or more
frequently as indicated
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29. INDICATORS OF LABOR PROGRESS ON
THE PARTOGRAPH
Alert line- Cx dilatation of the least progressing 10%
of primi’s who had SVD
oA rate of 1cm/hr
oAny progress <1cm/hr ( crosses alert line ) - Slow
progress
Further evaluation as to the specific cause, OR
Referral
Action line – an arbitrary line four hours parallel and
to the right of the action line
oIf labor progress crosses the action line
significant delay and needs urgent evaluation & intervention
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30. FOR WHOM TO USE A PARTHOGRAPH
1st make sure that:-
There are no complications of pregnancy that require
immediate action
The women is in labor
False labor is R/o & the partiunent in active phase of
1st stage of labour
It can be used for all labors:
In a hospital (including breech, multiple pregnancy,
previous C/S...)
In the peripheral health units
Inductions & augmentations – begin filling the
partograph when labor is established
Not in 2nd stage of labour
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35. DYSTOCIA
Any labor in which the pattern of labor progress is
significantly different from accepted & recognized
patterns of labor progress in terms of:
Cervical changes,
Decent of fetal presenting part or
Profile of uterine contractions
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36. NORMAL LABOR
Dynamic process
Uterine contractions that increase in :
Regularity
Intensity and
Duration
Causing progressive dilatation & effacement of the cervix
Permit descent of the fetus through the birth canal
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37. NORMAL LABOR…
Normal labor is characterized by:
1. Spontaneous onset
2. Rhythmic and regular uterine contraction
3. Vertex presentation
4. Vaginal delivery with out active interventions
5. Reasonable time
6. No maternal or fetal complications
38. FRIEDMAN’S NORMAL LABOR
PATTERN CURVE
Friedman describid normal labor pattern in
primigravids and multíparas in 1950’s
Using the 95th percentil valué as the upper limit of
normal, he described 4 abnormal patterns of labor
He divided labor into three functional divisions:
1. The preparatory division,
2. Dilation division, and
3. Pelvic division
Sigmoid curve
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first stage of labor
second stage of labor
40. FRIEDMAN’S CURVE FOR NULLIPARA –
CERVICAL DILATATION AND DESCENT
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0
1
2
3
4
5
6
7
8
9
10
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
tiempo en trabajo de parto (hrs)
dilatación
cervical
(cm)
Acceleration
Phase of
maximum
slope
Deceleration
Latent phase Active phase 2nd Stage
41. ETIOLOGIES OF ABNORMAL LABOR
Related to one of the four p’s of labor determinants– 4
p’s
Abnormalities of :
1. Powers
2. Passage
3. Passanger
4. Psychologicology
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42. ETIOLOGIES OF ABNORMAL LABOR...
1) Abnormalities of the powers
o Primary power – uterine contraction
o Secondary power – maternal expulsive efforts…
2) Abnormalities of the passages
o Contraction of the bony pelvis –inlet, midpelvic , outlet
o Soft tissue dystocia – tumor previa, vaginal septa etc
3) Abnormalities of the passenger
4) Psychological factors
o Often due to stress of labor affecting autonomic
nervous system
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43. ETIOLOGIES…
Abnormalities of the power–
Primary uterine inertia –
o Abnormal uterine contraction frequencies, duration & intensity
that is due to inherent myometrial dysfunction
o Mainly affects primigravid labors without other additional
factors
Secondary uterine inertia – causes
oProlonged labor
oMalpresentations/ malpositions
oEpidural analgesia
o Uterine myomata
oDehydration and electrolyte imbalances
oFetopelvic disproportion
oAbruptio placentae with couvaliare uterus
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44. ABNORMALITIES OF THE PASSENGER
(FETUS) LEADING TO DYSTOCIA
Macrosomia
Multifetal gestation
Congenital anomalies – e.g. hydrocephalus
Malpresentations/ Malpositions
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45. INCIDENCE
Nulliparas - 25% of all labors
Multiparas - 10% of all labors
40% of the indications for C/S, (EUA, 1994)
o 50% of primary C/S
o 21% of repeat C/S
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46. CLASSIFICATIONS OF ABNORMAL
LABOR PATTERNS –
Four major groups:
1) Prolongation disorders
2) Protraction disorders
3) Arrest Disorders
4) Precipitate labor
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47. PROLONGATION DISORDERS
Only one prolongation disorder recognized in 1st stage
Disorders of the Latent Phase
o A latent phase lasting >14 hrs in a multigravida & 20 hrs in a
primigravida
oChallenge in diagnosis is often due to the problem in
diagnosing the exact time of onset of labor
The 95th %iles for maximum length in latent labor:
o20 hours for nulliparous & 14 hours for multiparous
oThe upper limits for time spent in latent labor
Mean duration of latent labor:
Nullipara-6.4 hrs &
Multi – 4.8 hrs
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48. PROTRACTION DISORDERS
Two protraction disorders
1. Protracted cervical dilatation
o A cervical dilatation <1.2 cms in the multigravida and
1.5 cms in the primigravida during active labor
2. Protracted descent
o Descent of the fetal presentation less than 1 cms per
hour in the multigravida and 2 cms per hour in the
primigravida
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49. ARREST DISORDERS
a) Prolonged deceleration Phase
Deceleration phase > 3 hrs in nullipara
> 1 hr in Multi
b) Secondary arrest of dilatation
No progressive cervical dilatation for 2 hrs or more
c) Arrest of descent (Failure of descent)
Descent fails to progress for > 1 hr
Descent fails to occur in the deceleration phase
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50. DISORDERS OF THE SECOND STAGE
The median duration of the second stage is 50 to 60 minutes
for nulliparas and 20 to 30 minutes for multiparas
Factors influencing the length of the second stage include
parity, maternal size, birth weight, OP position, fetal station
at complete dilation, and, potentially, conduction anesthesia
For nulliparous women, the diagnosis should be considered
when the second stage exceeds 3 hours if regional anesthesia
has been administered or 2 hours if no regional anesthesia is
used, and in multiparous women, the diagnosis can be made
when the second stage exceeds 2 hours with regional
anesthesia or 1 hour without
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51. PRECIPITATE LABOR
Precipitous labor refers to delivery of the infant in less
than 3 hours
This occurs in approximately 2% of all deliveries
Short labors can be associated with placental abruption,
uterine tachysystole, and recent maternal cocaine use—
all of which are major contributors to poor outcomes for
mothers and infants
Two precipitate labor disorders
a) Precipitate dilatation
Primigravida > 5 cm/hr
Multigravida > 10 cm/hr
b) Precipitate descent
Primigravida > 5 cm/hr
Multigravida > 10 cm/hr
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52. DIAGNOSIS
History & Physical examination
Partograph
Document the following parameters against time
o Uterine contraction profile
o Cervical dilatation/effacement
o Descent of fetal presentation
Compare against normal patterns for respective parity, identify any
deviations and then classify into respective abnormal patterns
Look for specific etiology responsible for the abnormal
labor patterns by:
o Carefully assess the 4 determinants of labor progress (P’s
of labor)
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53. EVALUATION FOR CAUSES OF ABNORMAL LABOR
PATTERNS – ASSESSMENT OF THE 4 P’S OF
LABOR
Assessment of powers of labor – three ways
1) Palpation of uterine contractions
2) External tocodynamometer
3) Intrauterine pressure catheter monitoring
oMaternal exhaustion, vital signs, blood glucose and
evidence of dehydration
Assessment of the passenger
oSize, number, presentation, position and anomalies of
the fetus by Leopold's palpations & ultrasonography
Assessment of the passages
oBony pelvis – clinical pelvimetry
oSoft tissue dystocia – vaginal exam
Assessment of maternal emotional status and pain
control 53
54. MANAGEMENT OF ABNORMAL LABOR –
DEPENDS ON SPECIFIC ETIOLOGY DIAGNOSED
Power abnormalities
Uterine inertia – Augmentation
Secondary powers failure – Instrumental assistance
Passenger abnormalities
Often caesarean deliveries required
Destructive deliveries in cases of fetal deaths
Abnormalities of the passages
Often Caesarean delivery
Episiotomy for perineal level obstruction
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