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Effective Perinatal Care (EPC) PARTOGRAM Keywords  Prolonged labour  Preventing  WHO Effective Perinatal Care (EPC)  Partograph 3MO-2 3MO-2 Learning objectives  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 Effective Perinatal Care (EPC)  At the end of this module, the participants will: labour 3MO-3 3MO-3 What is a Partograph? The partograph is a means of graphic presentation of labour:  Progress of labour • Cervical dilatation • Foetal head descent Effective Perinatal Care (EPC) Definition: A tool to assess & interpret the progress of labour • Uterine contractions  Foetal status  Maternal status 2MO-4 2MO-4 Record Record Recordfoetal foetalcondition conditionincluding: including: Foetal Foetalheart heartbeat beatrate rate Moulding Mouldingofofthe thefoetal foetalhead head Condition Conditionofofamniotic amnioticfluid fluid Record Recordmaternal maternalcondition: condition: Pulse Pulseand andblood bloodpressure pressure Body Bodytemperature temperature Urine Urine(quantity, (quantity,presence presenceofofprotein proteinand andacetone) acetone) Drugs Drugsadministered administeredincluding includingOxytocin OxytocinIV IVfluids fluids Record Recordprogress progressof oflabor: labor: Cervical Cervicaldilatation dilatation Descent Descentofofthe thehead head Uterine Uterinecontractions contractions Why it is important to record the progresse of labour? Documentation is important  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 Effective Perinatal Care (EPC) History of the Partograph: Friedman Curve, 1954 Friedman EA, 1954 2MO-7 2MO-7 Effective Perinatal Care (EPC) History of the Partograph: First Partograph, 1971 Philpott RH, et al, 1972 2MO-8 2MO-8 PARTOGRAM Friedman's partogram - 1954 phases of labour (base on dilatation of the cervix ) Active phase Latent phase Latent phase (dilatation < cm) Active phase (>3 cm dilated) 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 Partograph: Effective Perinatal Care (EPC) History of the WHO, 1988 2MO-10 2MO-10 Effective Labour Augmentation Criteria  Three to four contractions in 10 minutes, each lasting more than 40 seconds  Progress in cervical dilatation no less than cm per hour – Reassess progress by vaginal examination hours after a good contraction pattern with strong contractions has been established AND/OR  Descent of foetal head Ineffective Labour Augmentation Criteria  Good contractions are not established at maximum dose (32 mU per minute)  Cervical dilatation does not progress, or progress is less than cm per hour AND/OR  No descent of foetal head (if no signs of cephalopelvic disproportion or obstruction) Oxytocin Infusion Complications ) (1  Hyperstimulation – More than four contractions in 10 minutes, lasting longer than 60 seconds  If associated with a normal foetal heart rate pattern: – Decrease the oxytocin infusion rate – Reassess uterine activity to determine if any further interventions are required  If associated with foetal heart rate abnormalities: – Stop the oxytocin infusion and relax the uterus using tocolytics: Oxytocin Infusion Complications ) (2  Foetal heart rate abnormalities – Stop the oxytocin infusion – Place woman on her left side – Plan delivery:  If foetal heart rate abnormalities persist  Additional signs of distress (thick meconium-stained fluid)  If atypical variable decelerations, late decelerations, single prolonged deceleration grater than minutes Delay in the second stage of labour • The second stage of labour can be divided into a passive (pelvic) phase and active (perineal) phase • Delay in this stage of labour may be due to malposition causing failure of the vertex to descend and rotate, ineffective contractions due to a prolonged first stage, large fetus and large vertex, or absence of the desire to push with epidural analgesia • Time limits in second stage range from 30 to hrs for multiparae and 1–3 hrs for nulliparae Management • When a diagnosis of delay in the second stage has been made the case is referred to the obstetrician for review and assessment • The risk to both mother and fetus if the second stage is allowed to exceed normal time limits must be weighed against the risks of intervening with an instrumental or operative delivery • Where there is any indication that the mother or the fetus is compromised the birth must be expedited as soon as possible Precipitate labour • In some women, the uterus is over-efficient and the onset of labour to birth is an hour or less • Much or all of the first stage is not recognized because contractions are not painful and the realization of the birth of the head may be the first indication that labour has actually started Risk • Soft tissue trauma of the maternal genital tract • Fetal Hypoxia • Fetal Intracranial haemorrhage • Fetal head and body injury • Retained placenta and/or postpartum haemorrhage • The psychological impact of such a rapid birth must not be underestimated Management • Precipitate labour will often recur in subsequent pregnancies and the obstetrician may advise induction of labour once term (37 completed weeks) is reached • Working together as a team can only help to contribute to that positive birth experience Conclusions  Labour abnormalities can be revealed in a timely manner by using the WHO Partograph  Create a warm and friendly atmosphere in the maternity, have a companion present during labour and birth, encourage food and fluid consumption and upright position to reduce the rate of prolonged labour  Early amniotomy should not be routinely used  Amniotomy should be reserved for women when labour progresses abnormally  Oxytocin should be used with caution, followed by closely monitoring the progress of labour, and the condition of mother and baby Partograph showing normal labor   Partograph showing prolonged active phase of labor Secondary arrest of cervical dilatation Secondary arrest of head descant !Thank You L/O/G/O With best wishes , RN laila M Elmasharfa ... glucose, acetone • Urine output • PARTOGRAM WHAT NEED TO BE RECORDED PARTOGRAM RECORDING Notes should be legible, dated and timed Begin plotting at the “zero” hour on the partogram All entries made... History of the Partograph: First Partograph, 1971 Philpott RH, et al, 1972 2MO-8 2MO-8 PARTOGRAM Friedman's partogram - 1954 phases of labour (base on dilatation of the cervix ) Active phase Latent... should be stopped when – Complications requiring urgent delivery arise 2MO-14 2MO-14 Component of Partogram Mother information Fetal well-being Fetal heart rate • Character of liquor • Moulding