Partographic monitoring of labor

Normal Labor and Childbirth: Conclusion

• Have a skilled attendant present

• Use partograph
• Use specific criteria to diagnose active labor
• Restrict use of unnecessary interventions
• Use active management of third stage of labor
• Support woman’s choice for position during labor
and childbirth
• Provide continuous emotional and physical
support to woman throughout labor
2
 Partographic Mx of Labor ( use of partogram )

•Partograph (recently named partogram ) is a graphic recording of

the progress of Labor and the condition of the mother and fetus
•It is recommended to be used to monitor the progress of labor in
all delivery suites by skilled person for using it.
•This is because it serves as an “ early warning system” and assists
in early decision on transfer, augmentation and termination of
labor.
•It detects abnormal labor early & helps to recognize CPD long
before labor becomes obstructed.
•It also increases the quality and regularity of all observations on
the fetus and mother and aids early recognition of problems with
either;
•It has been shown to be effective.
 It has been shown to be effective
• In Preventing prolonged labor ( need for augmentation)
• improving neonatal out come. ( intra partum still birth)
• WHO partograph:_ is composed of a graph with places for
recording of:-

* Fetal Condition (FHR, membranes and liquor and molding )

* Progress of labor (dilatation, descent and uterine contractions)
* Maternal condition (PR, B/P, To , Urine Volume, protein and
acetone, drugs and IV fluids and Oxytocin regime ).

• It has been modified recently 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 cm dilated.
Partograph
 Criteria for application:- (use ) of partograph on a case:

1. Requirements for its implementation fulfilled

( qualified and trained staff around, WHO Partograph
is available_)
2. No complication of pregnancy that require immediate
action.
3. Labor reached active phase (>4 cm cervical dilatation)
4. Labor not at advanced stage > 8 cm dilatation)
5. Absence of conditions that require special monitoring
e.g uterine scar, malpresentations or fetal anomalies .
 Using the Partograph
• Patient information: Name, gravida, para, hospital
number, date and time of admission, and time of
ruptured membranes
• Fetal heart rate: Record every half hour
• Amniotic fluid: Record the color at every vaginal
examination:
– I: membranes intact
– C: membranes ruptured, clear fluid
– M: meconium-stained fluid
– B: blood-stained fluid
7
 Using the Partograph (continued)
• Hours: Time elapsed since onset of active phase of labor
(observed or extrapolated)
• Time: Record actual time
• Contractions: Chart every half hour; palpate the number of
contractions in 10 minutes and their duration in seconds
– Less than 20 seconds:
– Between 20 and 40 seconds:
– More than 40 seconds:
• Oxytocin: Record amount per volume IV fluids in drops/min.
every 30 min. when used
• Drugs given: Record any additional drugs given

8
 Using the Partograph (continued)
• Descent assessed by abdominal palpation:
Part of head (divided into 5 parts) palpable
above the symphysis pubis; recorded as a
circle (O) at every vaginal examination. At 0/5,
the sinciput (S) is at the level of the symphysis
pubis

9
 Using the Partograph (continued)
• Molding:
– 1: sutures apposed
– 2: sutures overlapped but reducible
– 3: sutures overlapped and not reducible
• Cervical dilatation: Assess at every vaginal
examination, mark with cross (X)
• Alert line: Line starts at 4 cm of cervical dilatation to
the point of expected full dilatation at the rate of 1
cm per hour
• Action line: Parallel and 4 hours to the right of the
alert line
10
 Using the Partograph (continued)
• Temperature: Record every 2 hours
• Pulse: Record every 30 minutes and mark with
a dot (•)
• Blood pressure: Record every 4 hours and
mark with arrows
• Protein, acetone and volume: Record every
time urine is passed

11
Sample Partograph

for Normal Labor

12
Partograph Showing Prolonged
Active Phase of Labor

13
Partograph Showing
Obstructed Labor

14
Partograph Showing
Inadequate Uterine
Contractions
Corrected
with Oxytocin

15
Management of labor:- With abnormal progress on Partograph;
1. Normal Progress in active phase,
= ( remains to the left of alert line (or latent phase
< 8 hours if old version used )
= Do not augment or intervene unless complications develop
= ARM Postponded for spontaneous rapture in late stage
2. Progress between alert and action line.

• In a health center:- transfer to hospital with

facilities for C/S unless the cervix is almost
fully dilated.
• ARM may be performed if still intact and
observe progress for a short period of time
before transfer.
• In hospital:- Perform ARM if intact and
continue routine observations.
 3. Progress at labor beyond action line

– Full medical assessment

– Consider IV infusion/ bladder catheterization/ analgesia options
I. Delivery ( normally C/S) if fetal distress or obstructed labor .
II. Oxytocin augmentation by IV infusion, if no contra indication
III. supportive therapy only ( if progress now established and
dilatation could be anticipated at > 1 cm / hour)
• Further review ( in cases continuing in labor)
• Vaginal examination after 3 hours; then in > 2 hrs; then in > 2
hours
• Failure to make satisfactory progress ( dilatation < 1 cm / hour) between
any of these examinations, means C/S delivery is indicated
4. Prolonged latent phase ( 8 hours, under observation )

• Full medical Assessment.

Options
i. No action ( Woman not in labor, abandon Partograph)
ii. Delivery by C/S ( if fetal distress or factors likely to lead to
obstruction or other medical complications necessitating
termination of labor)
iii. ARM+ Oxytocin ( if contraction pattern & / or cervical assessment
suggest continuing true labor
• Further review ( in cases continuing in labor) Continuing P/v once
every 4 hours, up to 12 hours. If not in active phase after 8 hrs of
oxytocin deliver by C/S
• If Active Phase is reached in <8 hours but progress in active phase is
< 1 cm/hour, delivery by C/S may be considered.
Postpartum care provision includes:
• Ongoing supportive care up to discharge
-check V/S; uterine tone & Vag. Bleeding Q.15mins for the
first 2hrs [Mx of 4th stage]
• Basic care provision for mother and newborn
– Breastfeeding and breast care
– Complication readiness plan
– Support for mother-baby-family relationships
– Newborn care
– Family planning
– Nutritional support
– Self-care and other healthy practices
– HIV counseling and testing
– Immunizations and other preventive measures
• Care is individualized according to woman’s and newborn’s needs,
history, and other findings
20