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PARTOGRAM

PARTOGRAM. Learning objectives. At the end of this module, the participants will: Know the history and the background of the partograph Understand the effectiveness of the partograph for improving perinatal outcomes Know how a partograph is used and how to complete one

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PARTOGRAM

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  1. PARTOGRAM

  2. Learning objectives • At the end of this module, the participants will: • Know the history and the background of the partograph • Understand the effectiveness of the partograph for improving perinatal outcomes • Know how a partograph is used and how to complete one • Be able to interpret the partograph and use it to make decisions in managing labour

  3. What is a Partograph? Definition: A tool to assess & interpret the progress of labour. The partograph is a means of graphic presentation of labour: Progress of labour Cervical dilatation Foetal head descent Uterine contractions Foetal status Maternal status

  4. Record • Record foetal condition including: • Foetal heart beat rate • Moulding of the foetal head • Condition of amniotic fluid • Record maternal condition: • Pulse and blood pressure • Body temperature • Urine (quantity, presence of protein and acetone) • Drugs administered including Oxytocin. • IV fluids. • Record progress of labor: • Cervical dilatation • Descent of the head • Uterine contractions:

  5. WHY IS IT IMPORTANT TO RECORD THE PROGRESS OF LABOUR • To provide continuity of care. • To provide a basis of decision making. • To facilitate research. • To allow audit and review. • To defend one’s actions – no documentation – no defense. Documentation is important

  6. History of the Partograph: Friedman Curve, 1954 Deceleration phase Phase of maximum slope Cervical dilatation (cm) Active phase Latent phase Time from commencement of labour Friedman EA,1954

  7. History of the Partograph: First Partograph, 1971 Philpott RH, et al, 1972

  8. PARTOGRAM Friedman's partogram - 1954 • 2 phases of labour (base on dilatation • of the cervix ) • Latent phase (dilatation < 3 cm) • Active phase (>3 cm dilated) Active phase Latent phase Philpott and Castle - 1972 Introduced the concept of “ALERT” and “ACTION” lines. ALERT LINE – represent the mean rate of slowest progress of labour ACTION LINE – appropriate action should be taken. Normal labour is plotted to the left alert line

  9. History of the Partograph: WHO, 1988

  10. The WHO Partograph, 1988 Benefits Effective standard for observing the progress of labour Provides early detection for the unsatisfactory progress of labour Detection of cephalopelvic disproportion before the obstruction appears Helps to make quick and logical decisions for managing labour Identifies the necessary interventions Simple, low cost, accessible and clear

  11. The Use of the Partograph Reduced:

  12. The partograph is used to record mainly the first stage of labour However, after full cervical dilatation is reached, you should continue to record vital information related to the mother and the fetus (foetal heart rate, uterine contractions, maternal pulse, and blood pressure) The partograph is started if there are Two or more uterine contractions in 10 min lasting 20 sec or more in the latent phase One or more uterine contractions in 10 min lasting 20 sec or more in the active phase No complications requiring urgent interventions or delivery Key Principles for Using the Partograph (1)

  13. The partograph is filled out during the labour not after birth During labour, the partograph must be kept in the labour room The partograph is filled in and interpreted by trained personnel (midwife or obstetrician) Filling in the partograph should be stopped when Complications requiring urgent delivery arise Key Principles for Using the Partograph (2)

  14. Component of Partogram 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

  15. PARTOGRAM WHAT NEED TO BE RECORDED

  16. PARTOGRAM RECORDING 3 Notes should be legible, dated and timed. 4 1 Enter the outcome of delivery Begin plotting at the “zero” hour on the partogram 2 All entries made in relation to time when the observations are made

  17. PARTOGRAM RECORDING Mother information • Name • Age • Parity • Gestational period • Date/time of admission • Time of rupture membrane • Shortantenatal history

  18. General Information Boiko I. 3 2 425 12.04.06 16:35 5

  19. PARTOGRAM RECORDING Fetal information • Fetal heart rate • Membrane and amniotic fluid • Moulding • Caput

  20. Part 1 : Fetal condition

  21. Fetal Heart (Charting) Basal fetal heart rate • brady >110-160< tachy Decelerations? yes/no Relation to contractions? • Early • Variable • Late

  22. PARTOGRAM RECORDING Fetal information Fetal heart rate monitoring Safe and reliable way of knowing fetus is well. Listen after each contraction for one minutes. Recorded ½ hourly (each square is ½ hour)

  23. PARTOGRAM RECORDING Fetal information Character of amniotic fluid State of liquor can assess in monitoring fetal condition. Observation to be recorded - Membrane intact record as “I” - Membrane rupture: a) liquor clear record as “C” b) meconium stained liquor “M” c) liquor absent record as “A” d) bloody “B”

  24. Amniotic Fluid • I – the membranes intact • C – clear amniotic fluid • В – blood-stained amniotic fluid • M – meconium-stained amniotic fluid • A – absent amniotic fluid

  25. PARTOGRAM RECORDING Fetal information Moulding of fetal skull Provide information about the adequacy of pelvis to accommodate fetal head Record the degree of moulding 0  bones separated +  bones touching but can be separated. ++  bone over lapping +++  bones over lapping severely

  26. Moulding the fetal skull bones

  27. Caput and Moulding

  28. Information about Foetal Status in Labour “I”, “C” “M”, “B”, “A” “O”,“+” “++”, “+++”

  29. PARTOGRAM RECORDING Part II- Labour Progress • Cervical dilatation • Descent • Uterine contraction

  30. Cervical Dilatation

  31. PARTOGRAM RECORDING Labour progress Dilatation and Descent Latent (0-3 cm) and Active (3-10 cm) phase. Dilatation of cervix plotted as “X” axis and Descent plotted as “O” axis. First vaginal examination done on admission is recorded. Subsequent vaginal examination is done every 2-4 hourly. Transfer from latent to active phase.

  32. Cervical Dilatation: Latent Phase X X X 13:00 09:00 10:00 11:00 14:00 15:00 16:00 17:00 12:00

  33. Descent of the Head Determined by Abdominal Examination Head is mobile above the pelvic brim Head accommodates the full width of five fingers above the pelvic brim = 5/5 Head is engaged Head is two fingers width above the pelvic brim = 2/5 WHO, 1994 WHO EURO, 2002

  34. PARTOGRAM RECORDING Labour progress recording in latent phase Plot dilatation as “X” Plot descent as “O” Latent phase + + At admission: - Dilatation  2 cm - Descent  -2 2 hours after admission: - Dilatation  2 cm - Descent  -1 As the dilatation is only 2 cm therefore the labour progress is in the latent phase

  35. Foetal Head Descent O O X X 08:00 09:00 12:00 11:00 10:00

  36. PARTOGRAM RECORDING Labour progress recording in active phase Plot dilatation as “X” Plot descent as “O” + Latent phase Active phase + + Latent phase +

  37. X O X X O O O X 14:00 16:00 17:00 20:00 18:00 19:00 15:00 17:00 13:00 Foetal Head Descent

  38. Foetal Head Descent X O X O 09:00 11:00 12:00 13:00 10:00

  39. PARTOGRAM RECORDING Cervical dilatation + Latent phase If labour progress well plotting of cervical dilatation should always remain to the left of alert line. If it cross to right of action line this warns that labour may be prolonged. + + +

  40. Active Phase: on the Left of the Alert Line 20:00 21:00 13:00 09:00 10:00 11:00 14:00 15:00 16:00 17:00 19:00 X X X X 12:00 18:00

  41. Active Phase: at the Alert Line X X X X 16:00 22:00 14:00 15:00 17:00 18:00 18:00 19:00 20:00 21:00

  42. Active Phase: on the Right of the Alert Line (1) X X X X 20:00 14:00 15:00 16:00 17:00 18:00 18:00 19:00 21:00 22:00

  43. Active Phase: on the Right of the Action line (2) X X X X X 14:00 15:00 16:00 17:00 18:00 18:00 19:00 20:00 21:00 22:00 23:00 00:00 01:00 02:00

  44. Active Phase: The Lines of Alert and Action 4 hours

  45. Effect of Different Partograph Action Lines on Birth Outcomes:2-hour versus 4-hour Action Line • Use of 2-hour partograph: • More frequent crossing of Action line • More interventions without improving maternal or neonatal outcomes • More women transferred to higher level of care • No differences in cesarean delivery rate or women dissatisfied with labor experience 2-hour Action line partograph has no advantages compared with 4-hour partograph Lavender T et al, 2006

  46. PARTOGRAM RECORDING Labour progress Uterine Contractions Observation is made ½ hourly Assess the frequency, duration. Each square represent 1 contraction felt in 10 minutes. Frequency – highlight the numbers of square. Duration – shade the contraction in the square. < 20 sec - Mild 20-40 sec - Moderate > 45 sec - Strong

  47. PARTOGRAM RECORDING Labour progress Recording the uterine on the partogram Nos. of Contraction in 10 mins 2 weak contractions in 10 minutes 5 strong contractions in 10 minutes 3 moderate contractions in 10 minutes

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