Partogram: clinical study to assess the role of Partogram ...
partogram
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1 The The Partogram Partogram Dr. C. Savona-Ventura MD, DScMed, FRCOG, Accr.Cert.OG, MRCP The Partogram • A graphic representation of the progress of labour – Cervicograph – Descent of Head [cf moulding] – Uterine contractions – Features that assist progress [membranes/augmentation/drugs] – Maternal condition [heart rate, BP, urinalysis] – Fetal condition [heart rate, liquor]
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Transcript of partogram
1
The The PartogramPartogram
Dr. C. Savona-VenturaMD, DScMed, FRCOG, Accr.Cert.OG,
MRCP
The Partogram
• A graphic representation of the progress of labour– Cervicograph– Descent of Head [cf moulding]– Uterine contractions– Features that assist progress
[membranes/augmentation/drugs]– Maternal condition [heart rate, BP, urinalysis]– Fetal condition [heart rate, liquor]
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Phases in progress of Labour
• LATENT PHASE:-» Nullipara Multipara» 8.6-20.6 hrs 5.3-13.6 hrs
• ACTIVE PHASE:-– Acceleration Phase ] 4.9-11.7 hrs 2.2-5.2 hrs
– Phase of Maximum Slope ]– Deceleration Phase 54 min-3.3 hrs 14 -53 min
• SECOND STAGE 57 min-2.5 hrs 18 -50 min
• THIRD STAGE up to 20 min
Labour progress - cervical dilatation
0
2
4
6
8
10
0 5 10 15 20
LATENT PHASE ACTIVE
PHASE
1st Stage of Labour
2nd Stage
1 cm/hr
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Latent Phase
• Poor rate of cervical dilatation but general preparation of cervix.
• Duration: Nullipara Multipara» 8.6-20.6 hrs 5.3-13.6 hrs
• Assessed using Bishop Score 0 1 2 3– Cervical dilatation 0 1-2 3-4 5-6+– Cervical effacement [%] 0-40 40-60 60-80 80+
[cm] 3 2 1 0– Cervical position Post Mid Ant– Cervical consistency Firm Mod Soft– Station re ischial spine [cm] -3 -2 -1,0 +1,+2
• The use of the partogram during the latent phase not of use since this would chart only cervical dilatation. We should use acervicograph.
Prolonged Latent Phase• Definition
– >20 hrs [nullipara]; >14 hrs [multipara]• Aetiology
– Excessive sedation– Unfavourable Cervix– Idiopathic [forced induction]– False Labour
• Outcome– 14% will go into a Protracted Active Phase
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Prolonged Latent Phase
• Management DIAGNOSISEVALUATE CAUSE
THERAPEUTIC REST
Progress to Active Phase
No Change
Membranes ruptured
Augmentation
Membranes Intact
False Labour
Active Phase
• Good rate of cervical dilatation; cervix fully effaced.• Rate: Nullipara Multipara Lower limit of Normal
» ~3.0 cm/hr ~5.7 cm/hr ~1.0 cm/hr
• The use of the partogram during the active phase is essential for good intrapartum management
• Draw ALERT & ACTION LINES at onset of active phase– At 2-3 cm dilatation with patient getting strong and regular
contractions. Slope at 1cm/hr; lines four hours apart
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Partogram - cervical dilatation
0123456789
10
TIME
CERV
ICAL
DIL
ATAT
ION
ALERT LINE
ACTION LINE
Uterine contractions
• Aim at:- strong & regular contractions• ASSESS DURATION OF CONTRACTION
– mild moderate strong– <20 sec 20-40 sec >40 sec
• ASSESS FREQUENCY OF CONTRATIONS– Number of contractions in last 10 min of each ½ hr.– increased frequency from 1:10 to 5:10 minutes
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Descent of head in fifths per abdomen
• Engagement at 2/5 and less• If 3/5 or more than CPD [absolute or
relative] is present
Vaginal assessment in relation to ischial spines not useful to define engagement since position of spines dependant on type of pelvis.
Prolonged Active Phase
• Definition – >6 hrs or >1.2 cm/hr [nullipara]; >5.2 hrs or >1.5 cm/hr [multipara]
• Aetiology– CephaloPelvic Disproportion [often relative]– Fetal head malposition: OP/OT– Idiopathic [early ARM]– Excessive sedation
• Outcome– 39% Po & 13% P1+ will go into Secondary Arrest
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Prolonged Active Phase
0123456789
10
TIME
CERV
ICAL
DIL
ATAT
ION
ALERT LINE
NORM AL
DYSFUNCTIONAL
ACTION LINE
Prolonged Active Phase
• Management DIAGNOSISEVALUATE CAUSE
HYPOTONIA
Augment
Normal Progress
Vaginal Delivery
HYPERTONIA
Augmented?
Reduce Dose
CPD
LSCS
2o Arrest
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Secondary Arrest of Active Phase
• Definition – No change in cervical dilatation over a period of 2hrs+. Cervix becomes
oedematous. Can occur at 4-7 cm dilatation or as a protracted Deceleration phase
• Aetiology– CephaloPelvic Disproportion [often absolute]– Fetal head malposition [OP/OT] or Malpresentation [breech]– Insufficient uterine action– Excessive sedation
• Outcome– Will require LSCS. If protracted deceleration beware of shoulder
impaction
Partogram - cervical dilatation
0123456789
10
TIME
CER
VIC
AL D
ILAT
ATIO
N
ALERT LINENORM AL2 ARRESTPROTRACTEDACTION LINE
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Secondary Arrest of Active Phase
• Management DIAGNOSISEVALUATE CAUSE
CPD head 3/5+
No CPD head 2/5-
Assess Uterine Activity
Optimal head 2/5
Sub-Optimal
Augment
No Response Good Response
Vaginal Delivery
LSCS
