dr.Mona Mariana

WHY MONITOR?The intrapartum period is probably the most dangerous and traumatic period a time associated with a high mortality and morbidity for both mother and child.Maternal and fetal monitoring are essential to pick up problems early and thus institute timely intervention.Eternal alertness for abnormalities essential a labour is only said to be normal after it is over

INTRODUCTIONA partograph is a composite graphical record of the observations made of a woman in labour on a single sheet of paper.It was developed and extensively tested by the World Health Organization (WHO 1994).Can serve as an early warning system & assist in making timely decisions on transfers (referrals), intervention (augmentation) &/or termination of pregnancy.

HISTORYEmanuelFriedman's partograph - 1954 Based on observations of cervical dilatation and foetal station against time elapsed in hours from onset of labour. The time of onset of labour was based on the patient's subjective perception of her contractility. Plotting cervical dilatation against time yielded the typical Sigmoid or 'S' shaped curve, and station against time gave rise to the Hyperbolic curve.

Philpott and Castle 1972 Introduced concept of "ALERT" and "ACTION" lines. Alert line was drawn at a slope of 1 centimetre/hr for nulliparous women starting at zero time i.e. time of admission .

Action line drawn four hours to the right of the alert line showing that if the patient has crossed the alert line active management should be instituted within 4 hours, enabling the transfer of the patient to a specialised tertiary care centre.

Studd's labour stencils - 1972Five separate patterns representing normal labour progression were constructed. The curves were transcribed onto acrylic stencils.

OTHER PARTOGRAPHSHand drawn Paper & Pencil.Round partograph.E partograph.

PARTOGRAPH

OBJECTIVESEarly detection of abnormal progress of labour. Prevention of prolonged labour. Recognize cephalopelvic disproportion long before obstructed labour.Assist in early decision on transfer, augmentation, or termination of labour.

OBJECTIVES (cont..)Increase the quality and regularity of all observations of mother and fetus.Early recognition of maternal or fetal problems.Highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc). Reduce incidence of CS rate.Facilitates handover procedure.

COMPONENTSPart I : Patient IdentificationPart II : Fetal conditionPart III : Progress of labourPart IV : Maternal conditionOutcome

Part I : PATIENT IDENTIFICATION

NameGravida Para Hospital numberDate and time of admissionTime of ruptured membranes.

Part II : FETAL CONDITION

Monitor and assess fetal condition1 - Fetal heart rate2 - Liquor3 - Moulding the fetal skull bones

FETAL HEART RATEMonitor every 30 mins in latent phase.Every 15 mins in active phase.Every 5 mins in 2nd stage of labour.Mark it with a dot & join the lines.Basal fetal heart rate?< 160 beats/min =tachycardia > 110 beats/min = bradycardia >100 beats/min = severe bradycardia

MEMBRANES AND LIQUORIntact membranes .. IRuptured membranes + clear liquor CRuptured membranes + meconium- stained liquor.. MRuptured membranes + blood stained liquor BRuptured membranes + absent liquor. A

MOULDING THE FETAL SKULL BONESMoulding is an important indication of how adequately the pelvis can accommodate the fetal head.Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic disproportion.Separated bones, sutures felt easily . OBones just touching each other +Overlapping bones (reducible)... ++Severely overlapping bones (nonreducible) .. +++

Part III : PROGRESS OF LABOURCervical dilatationDescent of the fetal headUterine contractionsFetal position

This section of the partograph has as its central feature a graph with a vertical scale on the left, numbered in the ascending order from 0 to 10 (Cervical dilatation in cms).

In same vertical scale descent of the fetal head as assessed by abdominal examination.

At the right in the descending order denotes the station of the fetal presenting part.

Horizontal scale represents hours spent in labour.

Points are entered as a cross (x) for cervical dilatation & station by a dot ().

Each observation is joined to the preceding one by a straight line.

The S shaped dilatational curve is divided into a latent phase and an active phase.

LATENT PHASE

It starts from onset of labour until the cervix reaches 3 cm dilatation.

Once 3 cm dilatation is reached, labour enters the active phase.

Lasts 8 hours or less.

At least 2/10 min contractions.Each lasting < 20 seconds.

ACTIVE PHASE

Contractions at least 3 / 10 minEach lasting < 40 secondsThe cervix should dilate at a rate of 1 cm / hour or faster.Further subdivided into Acceleration phase 2.5 4 cms.Phase of maximum slope 4 9 cms.Deceleration phase 9 10 cms.

This can also be divided into 3 functional divisions Preparatory division Including latent & acceleration phase.Dilatation division Phase of maximum slope.Pelvic division Deceleration phase.

ALERT LINEThe alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm/hour.

In a normal labour, cervical dilatation should be either on the alert line or to the left of it.

Moving to the right of the alert line means it falls on zone 2, it is abnormal & needs to be critically assessed.

ACTION LINEThe action line is drawn 4 hours to the right of the alert line and parallel to it.

This is the critical line at which specific management decisions must be made.

When it falls in zone 3 case should be reassessed by a senior person. Decision to be made for CS or augmentation of labour.

CERVICAL DILATATIONIt is the most important information and the surest way to assess progress of labour.

When progress of labour is normal and satisfactory, plotting of cervical dilatation remains on the alert line or to left of it.

If a woman arrives in the active phase of labour, recording of cervical dilatation starts on the alert line.

CERVICAL DILATATION (cont..) When the active phase of labor begins, all recordings are transferred and start by plotting cervical dilatation on the alert line using the letters TR.Leaving the area between the transferred recording blank. The broken transfer line is not part of the process of labor.Do not forget to transfer all other findings vertically.

DESCENT OF THE FETAL HEADIt should be assessed by abdominal examination immediately before doing a vaginal examination, using the Rule of fifth ( Crichton method ) to assess engagement.The rule of fifth means the palpable fifth of the fetal head is felt by abdominal examination above the level of symphysis pubis.When 2/5 or less of fetal head is felt above the level of symphysis pubis, this means that the head is engaged.

DESCENT OF THE FETAL HEAD (cont..)By vaginal examination, the lowest part of vertex has passed or is at the level of ischial spines in absence of caput, is said to be engaged head.

FETAL POSITIONSOcciput transverse positions

Occiput anterior positions

UTERINE CONTRACTIONSPalpate number of contractions in ten minutes and duration of each contraction in seconds

Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds:

Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase. Assessed by number of contractions in a 10 minutes period.Measured in seconds from the time the contraction is first felt abdominally, to the time the contraction passes off.Each square represents one contraction.

Part IV: MATERNAL CONDITIONAssess maternal condition regularly by monitoring:

Oxytocin Amount per volume IV fluids in drops per minute, every 30 mins. Conc in upper box & dose (mIU/min) in lower box. Drugs Any additional drugs given.IV Fluids used.

Part IV: MATERNAL CONDITIONPulse Every 30 mins & marked with a dot ().Blood pressure Recorded in vertical line every 4 hours & marked with arrows.Temperature Recorded every 2 hours. Urine volume , analysis for protein and acetone Everytime urine is passed.

MANAGEMENT OF LABOUR USING THE PARTOGRAPH

- Latent phase is less than 8 hours- Progress in active phase remains on or to the left of the alert line. Do not augment with oxytocin if latent and active phases go normally.No ARM in latent phase.ARM at any time in active phase.

Between alert and action lines In health center, the women must be transferred to a hospital with facilities for caesarean section, unless the cervix is almost fully dilated.Observe labor progress for short period before transfer.Continue routine observations.ARM may be performed if membranes are still intact.

At or beyond action line

Conduct full medical assessment.Consider intravenous infusion / bladder catheterization / analgesia.Options - Deliver by caesarean section if there is fetal distress or obstructed labour. - Augment with oxytocin by intravenous infusion if there are no contraindications.

ABNORMAL PROGRESS OF LABOR

One of the main functions of the partograph is to detect early deviation from normal progress of labor.

LABOUR TIME FRAMES

Phases/ Stages of labourNulliparousMultiparous

Latent phaseMean time 6.4 h 4.8 hLongest 20.1 h 13.6 hActive phaseMean rate 3 cm/h 5.7cm/h Slowest 1.2cm/h 1.5cm/h2nd StageMean time 1.1 h 0.4 hLongest 2.9 h 1.1 h

LATENT PHASENormal duration 8hrs in Primi & 4hrs in Multi.This is why there is a heavy line drawn on the partograph at the end of 8 hours of the latent phase.

PROLONGED LATENT PHASEIt is prolonged when its duration exceeds 20 hrs in Primi & 14 hrs in Multi.

According to WHO partograph, a prolonged latent phase is Cervix not dilated beyond 4cms after 8hrs from admission & with any changes in cervical effacement or dilatation.

PROLONGED ACTIVE PHASEIn the active phase of labor, plotting of cervical dilatation will normally remain on or to the left of the alert line. Moves to the right of the alert line warns that labor may be prolonged.Happens if the rate of cervical dilatation in active phase of labor is less than 1cm/hour for a minimum of 4hrs. At the action line, the woman must be carefully reassessed for why labor is not progressing and a decision made on further management.

PROLONGED DECELERATION PHASEDeceleration phase exceeds 3 hrs for nulliparas & 1 hour for multiparas.

SECONDARY ARREST OF CERVICAL DILATATIONWhen the cervical dilatation commences normally but stops or slows significantly for 2 hours or more prior to full dilatation of cervix.

SECONDARY ARREST OF HEAD DESCENT

Abnormal progress of labor may occur with normal progress of descent of the fetal head then followed by secondary arrest of descent of fetal head.

Diagnostic Criteria( In active labour)For Protracted dilatation, criteria are less than 1.2 cm per hour for primips and less than 1.5 cm per hour for multips.

For Protracted descent, the criteria are less than 1.0 cm per hour in primips and less than 2.0 cm per hour for multips.

PRECIPITATE LABOUR

- Maximum slope of dilatation of 5 cm/hr or more

POINTS TO REMEMBER

It is important to realize that the partograph is a tool for managing labor progress only.

The partograph does not help to identify other risk factors that may have been present before labor started.

Only start a partograph when you have checked that there are no complications of pregnancy that require immediate action.

A partograph chart must only be started when a woman is in labor -- be sure that she is contracting enough to start a partograph.

Fill up the patient details. Note the FHR & colour of liquor.

If progress of labor is satisfactory, the plotting of cervical dilatation will remain at or to the left of the alert line.

When labor progresses well , the dilatation should not move to the right of the alert line.

The latent phase 0 2 cm dilatation, is accompanied by gradual shortening of cervix. Normally, the latent phase should not last more than 8 hours.

The active phase, 3 10 cm dilatation, should progress at a rate of at least 1 cm/hour.

When the woman arrives in the latent phase, time of admission is 0 time.

When admission takes place in the active phase , the admission dilatation, is immediately plotted on the alert line.

Dilatation of the cervix is plotted/recorded with a (x), descent of the fetal head is plotted with a () and uterine contractions are plotted with differential shading.

Descent of the head should always be assessed by abdominal examination ( by the rule of fifths felt above the pelvic brim).

Assessing descent of the head assists in detecting progress of labor.

Increased moulding with a high head is a sign of cephalopelvic disproportion.

Vaginal examination should be performed infrequently as this is compatible with safe practice (once every 4 hours is recommended).

A woman whose cervical dilatation moves to the right of the alert line must be transferred and managed in an institution with adequate facilities for obstetric intervention, unless delivery is near.

When a womans partograph reaches the action line, she must be carefully reassessed to determine why there is lack of progress, and a decision must be made on further management.

When a woman in labor passes the latent phase in less than 8 hours i.e., transfers from latent to active phase, the most important feature is to transfer plotting of cervical dilatation to the alert line using the letters TR.

Note down the oxytocin conc & dose, drugs & iv fluids. Pulse, BP, Urine examination & Temperature.

ELECTRONIC PARTOGRAPH

A method of monitoring the progress of labor in a mother during childbirth, by attaching a position sensor to a predetermined point on the mother's pelvic bones; monitoring the location of the position sensor in three- dimensional space relative to a reference; and monitoring the location of the fetal presenting part with respect to the predetermined point on the mother's pelvic bones.

The location of the fetal presenting part may be indicated by a similar position sensor, or by imaging. Other conditions, such as effacement, cervical dilatation, and cervical position may also be monitored in a similar manner.

Full electronic capture of patient information during childbirth including - CTG, Partograph, All labour events, Outcome information.

Fetal blood sampling results and cord blood gases direct from the blood gas analyzer. This information can be shown in real time to enhance communication within and outside the delivery suite to improve patient care and reduce human error.

It can be accessed from anywhere, anytime, from within a hospital or from home..

COMPUTERIZED LABOUR MANAGEMENT To accurately and continuously measure cervical dilatation and fetal head station in labor and the fetal monitoring and maternal monitoring. An ultrasoundbased computerized labor management system was designed - The Fetal Monitoring System and The Maternal Monitoring System with The systems in-vivo generated individual Partographs with real time dilatation and head station measurements.

The measurements had accuracy of 5mm.

All parturients were comfortable throughout the insertion and the testing period.

There was no infection, bleeding or any significant local complication at any attachment site.

This system provides accurate continuous measurements of dilatation and station.

The method is superior to digital examination and provides real time diagnosis of non-progressive and precipitous labor.

The system is likely to reduce discomfort and infections associated with multiple vaginal examinations..

The Fetal Monitoring System Is a computer based training system that can be accessed from anywhere, anytime, from within a hospital or from a home.

The Maternal Monitoring System -

WHO PARTOGRAPH

The WHO partograph has been modified in 2000 to make it simpler and easier to use.

The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cms dilated.

Modified partograph - Indonesia 626 women; 20 midwives Referral rate increased Fewer vaginal exams Fewer augmented labour Fewer obstructed labour

(World Bank Tokyo April , 2010)

ADVANTAGESInexpensive technology which does not malfunction.A picture is worth a thousand words.Helps in continuity of care and providing information.Easy Handover Procedure.No major capital investment other than skilled attendant.

Documented evidence for Medico Legal purpose.Educational value for all grades of staff.

DISADVANTAGESAssumes that all women progress at same rate May influence intervention rate.Clinical findings have subjective variations. Loss of clinical autonomy.Lack of knowledge.Non availability of printed partographs.Duplication of recording.