3C                                               Skills workshop:                                               Recording ...
SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM   63Figure 3C-1: An example of a partogram
64    INTRAPAR TUM CARE           Time 06:00 10:00           Blood pressure 110/70 130/80           Pulse 70/min 90/min   ...
SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM           65 Time 06:00 10:00 14:00 Dilatation 2 cm 4 cm 6 cm...
66   INTRAPAR TUM CAREFigure 3C-6: Documenting medication, assessment, management and time on the partogram1. The name of ...
SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM        67satisfactory. On abdominal examination a          be...
68    INTRAPAR TUM CAREFigure 3C-7: Information from case sudy 1 correctly entered onto the partogram
SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM       69CASE STUDY 2                                        O...
70    INTRAPAR TUM CAREOn vaginal examination the cervix is 1 mm           1. How should you recordlong and 9 cm dilated. ...
SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM   71Figure 3C-8: Information from case study 2 correctly ente...
72    INTRAPAR TUM CAREFigure 3C-9: Information from case study 3 correctly entered onto the partogram
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Intrapartum Care: Skills workshop Recording observations on the partogram

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Intrapartum Care was developed for doctors and advanced midwives who care for women who deliver in district hospitals. It contains theory chapters and skills workshops adapted from the labour chapters of Maternal Care. monitoring the mother, fetus, and progress of labour, the second and third stages of labour, managing pain, the puerperium and family planning

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Intrapartum Care: Skills workshop Recording observations on the partogram

  1. 1. 3C Skills workshop: Recording observations on the partogram RECORDING THE Objectives CONDITION OF When you have completed this skills THE MOTHER workshop you should be able to: • Record and assess the condition of the A. Recording the blood pressure, mother. pulse and temperature • Record and assess the condition of the The maternal blood pressure, pulse and fetus. temperature should be recorded on the • Record and assess the progress of labour. partogram. B. Recording the urinary dataTHE PARTOGRAM 1. Volume is recorded in ml. 2. Protein is recorded as 0 to 4+.The condition of the mother, the condition 3. Ketones are recorded as 0 to 4+.of the fetus, and the progress of labour arerecorded on the partogram. RECORDING THE CONDITION OF THE FETUS C. Recording the fetal heart rate pattern The following two observations must be recorded on the partogram:
  2. 2. SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 63Figure 3C-1: An example of a partogram
  3. 3. 64 INTRAPAR TUM CARE Time 06:00 10:00 Blood pressure 110/70 130/80 Pulse 70/min 90/min Temp 37 °C 37.1 °C Volume 175 ml 150 ml Protein None None Ketones None + Glucose None None Blood None ++Figure 3C-2: Recording maternal blood pressure, pulse, temperature and urine results on the partogram LIQUOR: C = Clear liquor M = Meconium-stained liqourFigure 3C-3: Recording the fetal heart rate pattern and the liquor findings on the partogram1. The baseline heart rate. RECORDING THE2. The presence or absence of decelerations. If decelerations are present, you must record PROGRESS OF LABOUR whether they are early or late decelerations. F. Recording the cervical dilatationD. Recording the liquor findings Cervical dilatation is measured in cm and thenThree symbols are used: recorded by marking an ‘X’ on the partogram.I = Intact membranes.C = Clear liquor draining. G. Recording the length of the cervixM = Meconium-stained liquor draining. The length of the cervix (effacement) is recorded by drawing a thick, vertical line on the same part of the chart that is used for theE. How often should you record cervical dilatation. The length of the line drawnthe liquor findings? indicates the length of the endocervical canalThe recordings should be made: in cm. It is drawn on the chart whenever the1. At the time of each vaginal examination. cervical dilatation is recorded. Alternatively, the2. Whenever a change in the liquor is noted, length of the endocervical canal, measured in e.g. when the membranes rupture or if the cm or mm, can be noted in the space provided. woman starts to drain meconium-stained liquor after having had clear liquor before.
  4. 4. SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 65 Time 06:00 10:00 14:00 Dilatation 2 cm 4 cm 6 cm Length 2 cm 5 mm 2 mm Head above brim 4/5 3/5 2/5 Position ROP ROP ROP Moulding no no + Note: Transfer of recordings on chart from latent to active phase at 10:00.Figure 3C-4: Recording the cervical dilatation, cervical length, the amount of fetal head above the brim,position of the head and moulding on the partogram 06:00 1 weak contractions in 10 minutes 08:00 2 moderate contractions in 10 minutes 10:00 3 strong contractions in 10 minutes An infusion of one unit of oxytocin in one litre at 15 drops per minute is being administered from nine hours and at 30 drops per minute from 10 hours.Figure 3C-5: Recording the duration and frequency of contractions on the partogramH. Recording the amount of the contractions last less than 20 seconds (i.e.head palpable above the brim of the weak contractions), the block is striped if thepelvis (descent and engagement) contractions last between 20 and 40 seconds (i.e. moderate contractions) and the block isThe findings are recorded by marking an ‘O’ coloured-in completely if the contractionson the partogram. last more than 40 seconds each (i.e. strong contractions).I. Recording the position of the fetal headThe position of the fetal head is recorded L. Recording the frequency of contractionsby marking the ‘O’ with fontanelles and the The number of contractions occurring in 10sagittal suture. Alternatively, the position can minutes is recorded by marking off one blockbe noted (e.g. ROA) in the space provided. for each contraction, e.g. two blocks markedThis is recorded at every vaginal examination. off equals two contractions in 10 minutes, four blocks marked off equals four contractionsJ. Recording moulding of the fetal head in 10 minutes, and five blocks if five or moreThe degree of sagittal moulding (i.e. 0 to 3+) is contractions in 10 minutes.also recorded on the partogram. M. Recording drugs and intravenousK. Recording the duration of contractions fluid given during labourThe duration of contractions is also recorded In the space provided on the partogram youon the partogram. The block is stippled if the should record:
  5. 5. 66 INTRAPAR TUM CAREFigure 3C-6: Documenting medication, assessment, management and time on the partogram1. The name of the drug. observation is recorded, medication is given, an2. The dose of the drug given. assessment is made or management is altered.3. The time the drug was given.4. The type of intravenous fluid.5. The time the intravenous fluid was started. EXERCISES ON THE6. The rate of intravenous fluid administration. CORRECT USE OF7. The amount of intravenous fluid given THE PARTOGRAM (after completion). Only the information given in the cases willN. Assessment and management be shown on the partogram. In practice, allAfter each examination an assessment must the appropriate spaces on the partogrambe made and recorded on the partogram. All must be filled in.management in labour must also be recordedon the partogram. CASE STUDY 1O. Recording the time on the partogram A primigravida at term is admitted to aThe time, to the nearest half hour, should also primary care perinatal clinic at 06:00 withbe entered on the partogram whenever an a history of painful contractions for several hours. The maternal and fetal conditions are
  6. 6. SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 67satisfactory. On abdominal examination a between 30 seconds each, are noted. Onsingle fetus with a longitudinal lie is found. vaginal examination the cervix is 2 mm longThe presenting part is the fetal head, and 4/5 and 5 cm dilated. The head is in the rightis palpable above the brim of the pelvis. Two occipito-anterior position. The membranescontractions in 10 minutes, each lasting 15 are artificially ruptured and the liquor isseconds are noted. On vaginal examination the found to be clear.cervix is 1 cm long and 2 cm dilated. The fetalhead is in the right occipito-lateral position. 4. Is the woman still in the latent phase of labour?1. Is the woman in active labour? No. The cervix is more than 3 cm dilated.No. The cervix is less than 3 cm dilated. Therefore she in the active phase of labour.Thefore the woman is still in the latent phaseof labour. 5. Where should you enter the findings obtained at 10:00?2. How should you enter your The findings must be entered on the latentfindings on the partogram? phase part of the partogram, four hours toAs the woman is still in the latent phase of the right of the findings at 06:00. However,labour, the descent and amount of fetal head as the woman is now in active labour, thispalpable above the brim, the presenting part information must then be transferred to theand the position of the head, the length and active phase part of the partogram. This mustdilatation of the cervix must be recorded on be indicated with an arrow.the vertical line forming the left hand marginof the latent phase part of the partogram. The 6. How should you transfer the findingscorrect way of entering the above data on the at 10:00 from the latent to the activepartogram is shown below in figure 3C-7. phase part of the partogram? The X (cervical dilatation) must be moved3. How should you manage horizontally to the right until it lies on thethis woman further? alert line. This will again be at 5 cm dilatation.The woman must have the routine observations The O (number of fifths of the head above theperformed at the usual intervals, e.g. pulse pelvic brim) is similarly transferred to lie onrate, blood pressure and fetal heart. She the same vertical line opposite the two lines onmust be offered analgesia and sedation. the vertical axis. The new position of the headAdequate analgesia, e.g. pethidine 100 mg and (ROA) must be indicated on the O. The lengthhydroxyzine 100 mg or promethazine 25 mg, of the cervix is recorded by a 5 mm thick blackshould be given by intramuscular injection column on the base line vertically below theas soon as she asks for pain relief. A second X and O. The fact that the membranes havecomplete examination should be done at been ruptured is entered in the block provided10:00, i.e. four hours after the first complete for medication/ I.V. fluids/management. Aexamination. The woman must be encouraged ‘C’ in the block provided for liquor indicatesto walk about as this will help the progress that the liquor is clear. The correct method oftowards the active phase of the first stage of transferring the above findings from the latentlabour. to the active part of the partogram is shown in figure 3C-7. (The length of the cervix and theAt the second complete examination the position of the fetal head may also be enteredmaternal and fetal conditions are satisfactory. in the appropriate blocks provided elsewhereOn abdominal examination 2/5 of the fetal on the partogram.)head is palpable above the brim of the pelvis.Three contractions in 10 minutes, lasting
  7. 7. 68 INTRAPAR TUM CAREFigure 3C-7: Information from case sudy 1 correctly entered onto the partogram
  8. 8. SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 69CASE STUDY 2 On abdominal examination the head is 3/5 palpable above the brim of the pelvis. Three contractions in 10 minutes, each lasting 25A multigravida is admitted to the labour ward seconds, are noted. On vaginal examinationat 08:00 in labour at term. The maternal and the cervix is 5 mm long and 5 cm dilated withfetal conditions are satisfactory. On abdominal bulging membranes.examination the head is 5/5 palpable abovethe brim of the pelvis. Three contractions in The presenting part is in the left occipito-10 minutes, each lasting 25 seconds are noted. transverse position. Poor progress isOn vaginal examination the cervix is 1 mm diagnosed and a systemic assessment of thelong (i.e. fully effaced) and 4 cm dilated. The woman is made in order to determine thepresenting part is in the left occipito-posterior cause. Intact membranes and inadequateposition. The woman complains that her uterine contraction are diagnosed as thecontractions are painful. causes of the poor progress.1. Is the woman in the active 4. How should you record thesephase of labour? findings on the partogram?Yes, as the cervix is more than 3 cm dilated. The X must be recorded on the horizontal line corresponding to 5 cm cervical dilatation, four2. How should you record your findings? hours to the right of the record at 08:00. The O, the position of the fetal head and length ofAs the woman is in the active phase of labour, the cervix, are recorded on the same verticalthe findings must be entered on the active line as the X. The correct way of recordingphase part of the partogram. The X (cervical these observations is shown in figure 3C-8.dilatation) is recorded on the alert line,opposite 4 on the vertical axis indicating 4 cm 5. Is the progress of labour satisfactory?dilatation. The O (number of fifths palpableabove the pelvic brim) is recorded above the X No. This is immediately apparent byopposite the 5 on the vertical line. The length observing that the second X has crossedof the cervix is recorded by a 1 mm column on the alert line. For labour to have progressedthe base line, vertically below the X and O. The satisfactorily, the cervix should have been atcorrect way of recording the above findings is least 8 cm dilated (4 cm initially plus 1 cmin figure 3C-8. per hour over the past four hours).3. How should you manage 6. How should you managethe woman further? this woman further?She must have the routine observations The membranes must be ruptured. Ruptureperformed at the usual intervals, e.g. pulse of the membranes will result in strongerrate, blood pressure, fetal heart, and urine uterine contractions. Because there has beenoutput. She must be offered analgesia. inadequate progress of labour, a third completePethidine 100 mg and hydroxyzine 100 mg examination should be performed at 14:00,or promethazine 25 mg should be given by i.e. two hours after the second completeintramuscular injection as soon as she requests examination.pain relief. A second complete examination At the third complete examination the maternalshould be done at 12:00, i.e. four hours after and fetal conditions are satisfactory. Onthe first complete examination. abdominal examination the head is 1/5 palpableAt the second complete examination the above the pelvic brim. Four contractions in 10maternal and fetal conditions are satisfactory. minutes, each lasting 50 seconds are observed.
  9. 9. 70 INTRAPAR TUM CAREOn vaginal examination the cervix is 1 mm 1. How should you recordlong and 9 cm dilated. The presenting part is in the above findings?the left occipito-anterior position. The findings As the woman is in the active phase of labour,are recorded as shown in figure 3C-8. the findings must be entered on the active phase part of the partogram. The X (cervical7. What is your assessment of the dilatation) is recorded on the alert lineprogress of labour at 14:00? opposite the 5 on the vertical line. The otherLabour is progressing satisfactorily. This is findings are entered in their appropriate placesshown by the third X having moved closer as shown in figure 3C-9.to the alert line. Also the head, which hasrotated from the left occipito-posterior to the 2. Is the decision to schedule the nextleft occipito-anterior position, is engaged. A complete examination at 13:00 correct?spontaneous vertex delivery may be expected Yes. There are no signs of cephalopelvicwithin an hour. disproportion (e.g. 3+ moulding) on admission, and the maternal and fetal conditions are satisfactory.CASE STUDY 3 3. What observations must be doneA gravida 2 para 1 is admitted to the labour carefully during the next four hours?ward at 09:00 in labour at term. She has alreadyhad painful contractions for the past two hours. Meconium in the liquor indicates that theTwo years before she had a difficult forceps fetus is at an increased risk for fetal distress.delivery for a prolonged second stage of labour. Therefore, the fetal heart rate pattern must beThe infant’s birth weight was 3000 g. The observed carefully for signs of fetal distressmaternal and fetal conditions are satisfactory. (e.g. late decelerations).On abdominal examination the head is 4/5palpable above the brim of the pelvis. The 4. What is likely to happen to thiscervix is 2 mm long and 5 cm dilated. There woman’s progress of labour?is 1+ of moulding present and the presenting The most likely outcome is the developmentpart is in the right occipito-posterior position. of cephalopelvic disproportion. On abdominalThe woman is HIV negative and an artificial examination the head will remain 3/5 orrupture of the membranes is performed and a more palpable above the pelvic brim (i.e.small amount of meconium-stained liquor is unengaged) and on vaginal examination theredrained. The woman is given pethidine 100 mg will be 3+ moulding. An urgent Caesareanand hydroxyzine 100 mg. A second complete section should then be performed.examination is scheduled for 13:00.
  10. 10. SK ILLS WORKSHOP : RECORDING OBSER VATIONS ON THE PAR TOGRAM 71Figure 3C-8: Information from case study 2 correctly entered onto the partogram
  11. 11. 72 INTRAPAR TUM CAREFigure 3C-9: Information from case study 3 correctly entered onto the partogram

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