WHO Partograph for Beginner

WHO Partograph For Beginner
• Dr Muhammad El Hennawy
• Ob/gyn specialist
• Rass el barr central hospital anddumya specialised hospital
• Dumyatt - EGYPT
• www.mmhennawy.8k.com

Partograph
• A partograph is a graphical record of the observations made of a women in labour
• For progress of labour and salient conditions of the mother and fetus
• It was developed and extensively tested by the world health organization WHO

History of Partogram
Friedman's partogram devised in 1954 was based on observations of cervical dilatation and foetal station against time elapsed in hours from onset of labour. The time onset of labour was based on the patient's subjective perception of her contractility. Plotting cervical dilation against time yielded the typical sigmoid or 'S' shaped curve and station against time gave rise to the hperbolic curve. Limits of normal were defined.

Philpott and Castle
• in 1973 introduced the concept of "ALERT" and "ACTION" lines. The aim of this study was to fulfill the needs of paramedical personnel practising obstetrics in Rhodesian African primigravidae. The alert line represented the mean rate of progress of the slowest 10% of patients in the African population whom they served. 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.
• The action line was subsequently drawn two hours to the right of the altert line

Studd's labour stencils
• It were introduced in 1972. These stencils predicted the expected pattern of progression of labour based on the extent of dilation achived by the time the patient is admitted (zero time). Curves showing the average course of cervical dilation were constructed for various dialation on admission. Five separate patterns representing normal labour progression were constructed. The curves were transcribed onto acrylic stencils. On admission in labour, the cervical dilation was assessed and a stencil was used to draw the relevant pencil line of expected progress on the patient's cervicograph which was then completed. Those crossing the nomogram line were found to have a three fold increase in instrumental delivery.

WHO partograph

Overview
• The partograph can be used by health workers with adequate training in midwifery who are able to:
– observe and conduct normal labour and delivery.
– Perform vaginal examination in labour and assess cervical dilation accurately
– plot cervical dilation accurately on a graph against time
• There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery
• Whether used in health centers or in hospitals, the partograph must be accompanied by a program of training in its use and by appropriate supervision and follow up

Objectives
• early detection of abnormal progess of a labour
• prevention of prolonged labour
• recognize cephalopelvic disproportion long before obstructed labour
• assist in early decision on transfer, augmentation, or termination or labour
• increase the quality and regularity of all observations of mother and fetus
• early recognition of maternal or fetal problems
• the partograph can be highly effective in reducing complications from prolonged labour for the mother (postpartum hemmorage, sepsis, uterine rupture and its sequelae) and for the newborn(death, anoxia, infections, etc.)

Partograph function
• The partograph is designed for use in maternity settings, but has a different level of function at different levels of health care
• in health center, the partographs critical function is to give early warning if labour is likely to be prolonged and to indicate that the woman should not be transferred to a hospital (ALERT LINE FUNCTION)
• in hospital settings, moving to the right of alert line serves as a warning for extra vigilance, but the action line is the critical point at which specific management decisions must be made
• other observations on the progress of labour are also recorded on the partograph and are essential features in managment of labour

Components of the partograph

• Part 1: fetal conditon (at top)
• Part 11: progress of labour (at middle)
• Part 111: maternal condition (at bottom)
• Outcome............:

Part 1 : Fetal condition
• this part of the graph is used to monitor and assess fetal condition
• 1 - Fetal heart rate
• 2 - membranes and liqour
• 3 - moulding the fetal skull bones
• Caput

Fetal heart rate
Basal fetal heart rate?
• > 160 beats/mi - tachycardia
• < 120 beats/min = bradycardia
• < 100 beats/min = severe bradycardia
Decelerations? yes/no
Relation to contractions?
• Early
• Variable
• Late---- Ausculation - return to baseline
≥ 30 sec → contraction
-------- Electronic monitoring peak and trough (nadir)
→ ≥ 30 sec

membranes and liqour
• intact membranes......................I
• ruptured membranes + clear liqour............C
• ruptured membranes + meconium -stained liquor ......M
• ruptured membranes + blood - stained liquor...........B
• ruptured membranes + absent liquor...........A

moudling the fetal skull bones
• Molding is an important indication of how adequately the pelvis can accommondate the fetal head
• increasing molding with the head high in the pelvis is an ominious sign of cephalopelvic disproportion
• separated bones. sutures felt easily............O
• bones just touching each other...........+
• overlapping bones (reducible 0.................++
• severely overlapping bones (non - reducible)....+++

part11 - progress of labour
• Cervical diltation
• Descent of the fetal head
Fetal position
• Uterine contractions
• this section of the paragraph has as its central feature a graph of cervical dilation against time
• it is divided into a latent phase and an active phase

latent phase:
• it starts from onset of labour until the cervix reaches 3 cm diltation
• once 3 cm diltation is reached, labour enters the active phase
• lasts 8 hours or less
• each lasting > 20 seconds
• at least 2/10 min contractions

Active phase:
• Contractions at least 3/10 min
• each lasting > 40 seconds
• The cervix should dilate at a rate of 1 cm/ hour or faster

Alert line (health facility line)
• The alert line drawn from 3 cm diltation represents the rate of dilation of 1 cm/ hour
• Moving to the right or the alert line means referral to hospital for extra vigilance

Action line (hospital line)
• The action line is drawn 4 hour to the right of the alert line and parallel to it
• This is the critical line at which specific management decisions must be made at the hospital

Cervical diltation
• It is the most important information and the surest way to assess progress of labour, even though other findings discovered on vaginal examination are also important
• when progress of labour is normal and satisfactory, plotting of cervical diltation remains on the alert line or left of it
• if a woman arrives in the active phase of labour, recording of cervical diltation starts on the alert line
• when the active phase of labor begins, all recordings are transferred and start by pltting cervical diltation on the alert line

Descent of the fetal head
• It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement
• The rule of fifth means the palpable fifth of the fetal head are felt by abdominal examination to be 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 engage, and by vaginal examination, the lowest part of vertex has passed or is at the level of ischial spines

Assesing descent of the fetal head by vaginal examination; 0 station is at the level of the ischial spine (Sp.)

Uterine contractions
• Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase
• frequency how often are they felt?
• Assessed by number of contractions in a 10 minutes period
• duration how long do they last?
Measured in seconds from the time the contraction is first felt abdominally, to the time the contraction phases off
• Each square represents one contraction

Palpate number of contraction in ten minutes and duration of each contraction in seconds
• Less than 20 seconds:
• Between 20 and 40 seconds:
• More than 40 seconds

Part 111: maternal condition
Name/ DOB / Gestation
Medical / Obsterical issues
Assess maternal condition regularly by monitoring:
• drugs, IV fluids, and oxytocin, if labour is augment
• pulse, blood pressure
• Temperature
• Urine volume, analysis for protein and acetone

Management of labour using the partograph

– latant phase is less than 8 hours
– progress in active phase remains on or left of the alert line
• Do not augment with oxytocin if latent and active phases go normally
• Do not intervene unless complications develop
• Articficial rupture of membranes (ARM)
• 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 afacilities for cesarean 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 in

At or beyond action line
• Conduct full medical assessment
• Consider intravenous infusion/ bladder catheterizaton / analegisa
• Options
– Deliver by cesarean section if there is fetal distress or obstructed labor
– 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

Moving to the right of alert line
• This means warning
• Transfer the woman from health center to hospital
• reaching the action line
• This means possible danger
• Decision needed on future management (usually by obesteritian or resident)

Prolonged latent phase
• If a woman is admitted in labor in the latent phase (less than 3 cm diltation) and remains in the latent phase for next 8 hours
• Progress is abnormal and she must be transferred to a hospital for a decision about further action
• This is why there is a heavy line drawn on the partograph at the end of 8 hours of the latent phase

Prolonged Active phase
• In the active phase of labour, plotting of cervical diltation will normally remain on or to the left of the alert line
• But some cases will move to the right of the alert line and this warns that labour may be prolonged
• This will happen if the rate of cervical diltation in the active phase of labor is not 1 cm/ hour or faster
• A woman whose cervical diltation moves to the right of the alert line must be transferred and managed in a hospital with adequate facilities for obstetric intervetion unless delivery is near
• at the action line, the woman must be carefully reassessed for why labor is not progressing and a decision made on further management

Secondary arrest of cervical diltation
• Abnormal progress of labor may occur in cases with normal progrss of cervical diltation then followed by secondary arrest of diltation

Secondary arrest of head descant
• Abnormal progress of labor may occur with normal progress of descent of the fetal head then followd by secondary arrest of descent of feal head

Precipitate Labor
– Maximum slope of dilation of 5cm/hr or more

USING THE PARTOGRAPH
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 labour 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
• if progress of labor is satifactory, the plotting of cervical diltation will remain or to the left of the alert line

• when labor proress well, the diltation should not move to the right of the alert line
• the latent phase. 0 -3 cm diltation, is accompanied by gradual shortening of cervix. normally, the latent phase should not last more than 8 hours
• the active phase , 3-10 cm diltation , should progress at rate of at least 1 cm/hour
• when admission takes place in the active phase, the admission diltation, is immediately plotted on the alert line

• when labor goes from latent to active phase, plotting of diltation is immediately transferred from the latent phase area to the alert line

• diltation of the cervix is plotted (recorded with an X, desent of the fetal head is plotted with an O, and uterine contractions are plotted with differential shading
• desent of the head should always be assessed by abdominal examination (by the rule of fifths felt above the pelvic brim) immediately before doing a vaginal examination
• assessing descent of the head assists in detecting progress of labor
• increasing molding 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)
• when the woman arrives in the latent phase, time of admission is 0 time
• a woman whose cervical diltation 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 woman's 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 (usually by an obesterician or resident)
• 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 diltation to 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

IMPORTANT CONSIDERATIONS

OXYTOCIN
• Oxytocics must be perserved in a cool, dark place
• A local regime may be used
• Oxytocin should be titrates against uterine contractions and increased every half- hour until contractions are 3 or 4 in 10 minutes, each lasting 40-50 seconds
• It may be maintained at the rate thoughout the second stage of labor
• Stop oxytocin infusion if there is evidence of uterine hyperactivity and / or fetal distress
• Oxytocin must be used with caution in muliparous women and rarely, if at all, in women of para 4 or more
• Augment with oxytocin only after artifical rupture of membranes and provided that the liquour is clear

MEMBRANES
• if membranes have been ruptured for 12 hours or more, antibiotics should be given
• As a first defense against serious infections, give a combination of antibiotics:
– ampicillin 2 g IV every 6 hours;
– PLUS gentaminicn 5 mg/kg bodyweigh IV every 24 hours;
– PLUS metronidazole 500 mg IV every 8 hours
Note:
If the infection is not severe, amoxicillin 500 mg by mouth every 8 hours can be used instead of ampicillin. Metronidazole can be given by mouth instead of IV.

FETAL DISTRESS
• If a woman is laboring in a health center, transfer her to a hospital with facilities for operative delivery
• In a hospital, immediately:
– Conduct a vaginal examination to exclude cord prolapse and observe amniotic fluid
– Provide adequate hydration
– Administer oxygen, if available stop oxytocin
– Turn the womna on her left side

Diagnosis of labour
Regular painful contractions resulting in progressive change of hte cervix
show
rupture of membranes

Components of normal labour
Patient
pain, bladder empty, dehydration, exhaustion
Powers
Uterine contraction
Maternal effort
Passages
Maternal pelvis (Inlet - Oulet)
Maternal soft tissue
Passenger
Fetal (size - presentation - position- Mouldind)
cord
placenta
membranes

The partograph in the management of labour following cesarean section
• In women undergoing a trial of labour following cesarean section, the partographic zone 2-3 h after the alert line represents a time of high rish of scar rupture. An action line in this time zone would probably help reduce the rupture rate without an unacceptable increase in the rate of cesarean section

ELECTRONIC PARTOGRAPH

• Full electronic capture of patient information during childbirth including,
• CTG's,
• partograms,
• all labour events,
• outcome information,
• fetal blood sampling results and cord blood gases direct from the blood gas analyser
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 over the anywhere, anytime, from within a hospital or from a home...

COMPUTERIZED LABOR MANAGEMENT
To accurately and continuously measure cervical dilatation and fetal head station in labor and the fetal monitoring and the mother monitoring
A ultrasound-based computerized labor management system was designed
The Fetal Monitoring System and
The mother Monitoring System with
The system's in-vivo generated individual Partograms with real time dilatation and head station measurements.
The measurements had accuracy of < 5 mm = 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 on-progressive and precipitious labor.
• The system is likely to reduce discomfort and infections associated to muliple vaginal examinations

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

The Mother Monitoring System