PARTOGRAPH

COMPONENTS OF PARTOGRAPH
● Mother information

❖ Name, Gravida, Para, Hospital numbe

❖ Date and time of admission

❖ Time of rupture membrane

● Fetal well being

❖ Fetal heart rate- The rate of the fetal heart indicates the state of fetus
inside the uterus. Record every half hour. Fetal heart rate plotted as (•)

DEFINITION OF PARTOGRAPH
● The partograph is the graphical presentation of the progress of labour, and
of fetal and maternal condition during labour.
OBJECTIVES OF PARTOGRAPH

1. Early detection of abnormal progress of labour.

2. Prevention of prolonged labour.
3. Recognize cephlopelvic disproportion long before obstructed labour.
4. Assist in early decision on transfer, augmentation, or termination of labour.
5. Early recognition of maternal and fetal problems.
6. Highly effective in reducing complication from prolonged labour for the
mother (PPH, sepsis, uterine rupture) and for the newborn( death, anoxia,
infection)
7. Reduce in incidence of C/S rate.
8. Increase the quality and regularity of all observation of mother and fetus.

CHARACTER OF AMNIOTIC FLUID

● Record the colour of amniotic fluid at every vaginal examination.
Intact membranes --------------------------------------------------- I
Ruptured membranes + clear liquor-------------------------------C
Ruptured membranes + meconium stain liquor------------------M
Ruptured membranes + blood stained liquor---------------------B
Ruptured membranes + absent liquor-----------------------------A

MOULDING OF FETAL SKULL

❏ Moulding is a state of reduction or loss of space between skull bones.

❏ Increasing moulding with the head high in the pelvic is an ominous sign of
Cephalopelvic disproportion

❏ Separated bones, suture felt easily --------------------------O

❏ Bones just touching each other--------------------------------+

❏ Overlapping bones (reducible)---------------------------------++

❏ Severely overlapping bones (not reducible) ----------------+++

CERVICAL DILATATION
● It is an essential part of partograph.
● Dilatation of cervix plotted as “X”
● Descent of fetal head plotted as “O”
● First vaginal examination done on admission is recorded.
● Subsequent vaginal examination is done every 4 hours.
● First alert line start at 4 cm cervical dilation and ends at 10 cm at the rate
of 1 cm /hour
 ● The action line is drawn to the right of the alert line this is critical line at
which specific management decision must be made at the hospital.
● Normal labour is plotted to the left alert line.
● Descent of Fetal Head
● Descent of fetal head plotted as “O”
● It should be assessed by abdominal examination immediate before doing a
vaginal examination using the “Rule of fifth”.

UTERINE CONTRACTION
● Observation of contraction is made half hourly in the active phase.
● Palpate the number of contraction in 10 minutes and duration of each
contraction in seconds
- Less than 20 seconds
- Between 20 to 40 seconds
- More than 40 seconds………………………….

MATERNAL WELL BEING

● Pulse: Record every 30 minutes and mark with the (•)
● BP: Record every 4 hours and mark with arrows.

URINE
● Volume
● Protein
● Acetone
 ACTUAL BIRTH SIMULATION
Sterile Procedures

● Sterile procedures are required before and during specific patient care
activities to maintain an area free from microorganisms and to prevent
infection.
● Performing a surgical hand scrub, applying sterile gloves, and preparing a
sterile field are ways to prevent and minimize infection during surgeries or
invasive procedures.

Application of Sterile Gloves

● Sterile gloves are gloves that are free from all microorganisms.
● They are required for any invasive procedure and when contact with any
sterile site, tissue, or body cavity is expected.
● Sterile gloves help prevent surgical site infections and reduce the risk of
exposure to blood and body fluid pathogens for the health care worker.
● Double gloving is known to reduce the risk of exposure and has become
common practice, but does not reduce the risk of cross-contamination after
surgery.

Setting Up a Sterile Field

Aseptic procedures require a sterile area in which to work with sterile objects.
A sterile field is a sterile surface on which to place sterile equipment that is
considered free from microorganisms
A sterile field is required for all invasive procedures to prevent the transfer of
microorganisms and reduce the potential for surgical site infections.
Sterile fields can be created in the OR using drapes, or at the bedside using a
prepackaged set of supplies for a sterile procedure or wound care.

Many sterile kits contain a waterproof inner drape that can be set up as part of
the sterile field.
Sterile items can be linen wrapped or paper wrapped, depending on whether they
are single- or multi-use.
Always check hospital policy and doctor orders if a sterile field is required for a
procedure.

Controlled Delivery of the Fetal Head

1. Engagement
2. Descent – entrance of the greatest biparietal diameter of the fetal head to
the pelvic inlet
3. Flexion – the chin of the fetus touches his chest enabling the smallest
diameter (suboccipitobregmatic) to be presented to the pelvis for delivery
4. Internal Rotation – when the head reach the level of the ischial spine, it
rotates from transverse diameter to AP diameter so that its largest
diameter is presented to the largest diameter of the outlet. This movement
allows the head to pass through the outlet.
5. Extension – the head of the fetus extend towards the vaginal opening. As the
head extend, the chin is lifted up and then it is born.
6. External Rotation – when the head comes out, the shoulder which enters the
pelvis in transverse position turns to anteroposterior position for it become in line
with the anteroposterior diameter of the outlet & pass through the pelvis.
7. Expulsion – when the head is born, the shoulder & the rest of the body follows
without much difficulties.
Duration of Second Stage: Primis – 50 mins
Multis – 20 mins
● Assessment: monitor FHT q 15 mins in normal case and every 5 mins in high
risk cases if not yet delivered
● Transfer to the DR: Primis – cervix fully dilated; Multis – cervix is 8 cm
dil

Delivery Position

Used when forcep delivery and episiotomy are to be performed

head of the bed is 35 – 45˚

elevated, knees are flexed & feet
flat on bed. This position
facilitates the pushing effort of
the mother.

Left lateral position- for woman with heart disease

Active Management of the Third Stage of Labor
Third Stage of Labor
● Birth of the baby and the delivery of the placenta and membranes
● Typically 10 to 30 minutes
● If> 30 minutes, considered to be prolonged
● If lasts longer than 18 minutes, with significant risk of PPH

Process of Active Management of Third Stage of Labor

1. Uterotonic drug
2. CCT
3. Massaging the uterus

Uterotonic Drugs
● Enhance contraction of the uterus
● Facilitate Expulsion of the Placenta
● Decrease Blood loss and are;
● Given after delivery of the baby, after ruling out presence of another baby
 Controlled Cord Traction (CCT)
● Technique to assist in expulsion of placenta
● Helps to reduce the chances of a retained placenta and subsequent
bleeding i.e. PPH
1. Place the clamp near the woman’s perineum to make CCT easier
2. Place the palm of the other hand on the lower abdomen just above the
woman’s pubic bone to assess for uterine contractions.
● If a clamp is not available, CCT can be applied by encircling the cord around
the hand.
1. As the placenta is delivered, hold and gently turn it with both hands until
the membranes are twisted.
2. Slowly pull to complete the delivery. Gently move membranes up and down
until delivered.
3. Ensure that placenta is delivered complete with all membranes. If the
placenta is not delivered after 30 minutes of delivery- refer
4. Give information regarding drugs given, their dose and time of
administration on referral slip
5. Never apply cord traction (pull) without contraction and without applying
counter traction (push) above the pubic symphysis with the other hand.

Immediate Essential Newborn Care

1. Time Bounded Interventions

- Immediate and thorough drying
- Early skin-to-skin contact
- Properly timed cord clamping
- Non-separation of the newborn and mother for early initiation of
breastfeeding
- 1.
- a. Time Band: Within 1st 30 secs (Immediate Drying)
- • Call out the time of birth
- • Dry the newborn thoroughly for at least 30 seconds
- – Wipe the eyes, face, head, front and back, arms and legs
- • Remove the wet cloth
- Do a quick check of breathing while drying
- Notes:
- During the 1st secs:
- Do not ventilate unless the baby is floppy/limp and not breathing
- Do not suction unless the mouth/nose are blocked with secretions or other
material

1.b Time Band: Within 10-3 mins (Thorough Drying)

- Notes:
- – Do not wipe off vernix
- – Do not bathe the newborn
- – Do not do footprinting
- – No slapping
- – No hanging upside - down
- – No squeezing of chest
2. Time Band: After 30 secs of Drying (Early Skin-Skin Contact)
 - If newborn is breathing or crying:
- – Position the newborn prone on the mother’s abdomen or chest
- – Cover the newborn’s back with a dry blanket
- – Cover the newborn’s head with a bonnet
- Notes:
- – Avoid any manipulation, e.g. routine suctioning that may cause trauma or
infection
- – Place identification band on ankle (not wrist)
- – Skin to skin contact is doable even for cesarean section newborns
3. Time Band: 1-3 mins (Properly timed-cord clamping)
● Remove the first set of gloves
● After the umbilical pulsations have stopped, clamp the cord using a sterile
plastic clamp or tie at 2 cm from the umbilical base
● Clamp again at 5 cm from the base
● Cut the cord close to the plastic clamp

Notes:
● – Do not milk the cord towards the baby
● – After the 1st clamp , you may “strip” the cord of blood before applying
the 2nd clamp
● – Cut the cord close to the plastic clamp so that there is no need for a 2nd
“trim”
● – Do not apply any substance onto the cord
4. Time Band: Within 90 mins (Non-seperation of newborn from mother
to early breastfeeding)
● Leave the newborn in skin-to-skin contact
● Observe for feeding cues, including tonguing, licking, rooting
● Point these out to the mother and encourage her to nudge the newborn
towards the breast
● Counsel on positioning
● – Newborn’s neck is not flexed nor twisted
● – Newborn is facing the breast
● – Newborn’s body is close to mother’s body
● – Newborn’s whole body is supported
● Counsel on attachment and suckling
● – Mouth wide open
● – Lower lip turned outwards
● – Baby’s chin touching breast
● – Suckling is slow, deep with some pauses
Notes:
– Minimize handling by health workers
– Do not give sugar water, formula or other prelacteals
– Do not give bottles or pacifiers
– Do not throw away colostrum

Uterine Massage

● Immediately after delivery of the placenta, massage the fundus of the

uterus through the woman’s abdomen until it is well contracted.
● Helps in contraction of the uterus and thus prevents PPH
● Ensure that the uterus does not become relaxed (soft) after the massage
● Watch for vaginal bleeding

1. Place the clamp near the woman’s perineum to make CCT easier
2. Place the palm of the other hand on the lower abdomen just above the
woman’s pubic bone to assess for uterine contractions.
3. As the placenta is delivered, hold and gently turn it with both hands until
the membranes are twisted.
4. Slowly pull to complete the delivery. Gently move membranes up and
down until delivered.
5. Ensure that placenta is delivered complete with all membranes. If the
placenta is not delivered after 30 minutes of delivery- refer
6. Give information regarding drugs given, their dose and time of
administration on referral slip
7. Never apply cord traction (pull) without contraction and without applying
counter traction (push) above the pubic symphysis with the other hand.
 IMMEDIATE POSTPARTUM CARE

A. Repair of Lacerations- Classification of Perineal Lacerations

1. First degree – involves the vaginal mucous membranes and perineal skin
2. Second degree – involves not only the muscles, vaginal mucous membranes
and skin, but also the muscles.
3. Third degree – involves not only the vaginal mucous membranes and skin,
but also the external sphincter of the rectum
4. Fourth degree – involves not only the external sphincter of the rectum, the
muscles, vaginal mucous membranes and skin, but also the m mucous
membranes of the rectum.
5. Assist the doctor in doing episiorrhaphy repair of episiotomy or
lacerations). In vaginal episiorrhaphy, packing is done to maintain pressure
on the suture line, thus prevent further bleeding. Note: Vaginal packs have
to be removed after 24 – 48 hours
6. After repair of lacerations & episiotomy, perineum is cleansed, the legs are
lowered from stirrups at the same time.
7. Make mother comfortable by perineal care and applying clean sanitary
napkin snugly to prevent its moving forward from the anus to the vaginal
opening. Soiled napkins should be removed from front to back.
8. Position the newly – delivered mother flat on bed without pillows to
prevent dizziness due to decrease in intraabdominal pressure.
9. 5. Check V/S of the mother every 15 mins for the first hour & every 30 mins
for the next 2 hours until stable.
10.6. Check uterus & bladder q 15 mins. A full bladder is evidenced by a
fundus which is to the right of the midline and dark – red bleeding with
some clots. Will prevent adequate uterine contraction.
 11.7. Fundus – should be checked every 15 minutes for 1 hour then every 30
minutes for the next 4 hours. Fundus should be firm, in the midline, and
during the first 12 hours postpartum, is a little above the umbilicus. First
nursing action for a non- contracted uterus: massage.
12.*Perineum – is normally tender, discolored and edematous. It should be
clean, with intact sutures.
13.*Blood pressure and pulse rate may be slightly increased from excitement
and effort of delivery, but normalize within one hour.

B. Apgar Scoring

Special Considerations:
1st 1 min – determine general condition of baby
Next 5 min- determine baby’s capabilities to adjust extra uterinely (most
important)
Next 15 min – (optional) dependent on the 5 min
A- appearance- color – slightly cyanotic after 1st cry baby becomes pink.
P- pulse rate – apical pulse – left lower nipple
G- grimace – reflex irritability- (1) tangential foot slap, (2) catheter
insertion
A – activity – degree of flexion or muscle tone
R – respiration - assessment of lungs
Baby cries – within 30 secs
Failure to cry after 30 secs – asphyxia neonatorum
 DANGER ASSESSMENT: Respiratory depression – due to Demerol (given to
the mother).– administer Naloxone

APGAR Result:
0 – 3 = severely depressed, need CPR, admission NICU
4 – 6 = moderately depressed, needs add’l suctioning & O2 administration
7 - 10 =good/ healthy