Partograph dr sunita
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Transcript of Partograph dr sunita
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PLOTTING A PARTOGRAPH
Dr Sunita Singal
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AimsAims
To understand the use of the To understand the use of the partographpartograph
Practice using the partographPractice using the partograph
To recognise slow progress in labour To recognise slow progress in labour and manage it appropriatelyand manage it appropriately
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Partograph:Partograph:
a graphical record of progress in laboura graphical record of progress in labour
Should be used for all deliveriesShould be used for all deliveries
Start using once the woman is in labourStart using once the woman is in labour
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LabourLabour
A correct diagnosis of labour has to be A correct diagnosis of labour has to be made before opening the partographmade before opening the partograph
2-3 uterine contractions in 10mins2-3 uterine contractions in 10mins Progressive shortening and thinning of the Progressive shortening and thinning of the
cervix during labour andcervix during labour and Cervical dilatation Cervical dilatation 4cm4cm or more dilated: or more dilated:
openopen partograph partograph
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Monitoring of first stage of labourMonitoring of first stage of labour
In Latent PhaseAfter 8 hours
Contractions stronger, more frequent, no change in dilatation or effacement ROM +/-
REFER to FRU
Prolonged latent phase
No increase in intensity / frequency / duration of contractions, membranes not ruptured and no progress in cervical dilatation
Ask woman to relax
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Beware of false labourBeware of false labour
Regular pains, but no progressive cervical dilatationRegular pains, but no progressive cervical dilatation Consider causes ? UTI, ? BV, ? infectionConsider causes ? UTI, ? BV, ? infection ? Prolonged latent phase? Prolonged latent phase
Contractions persist mild-moderateContractions persist mild-moderate At termAt term CX less than 3cmCX less than 3cm Membranes intactMembranes intact
BEWARE strong contractions without progress, check BEWARE strong contractions without progress, check lie, presentation- act fast- REFERlie, presentation- act fast- REFER
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True labour pains False labour pains
Regular and predictable Irregular
Felt first in lower back & sweeps towards lower abdomen
Remains confined to lower abdomen
Not relieved by rest Often relieved by rest
Increase in duration , intensity and frequency with time
Does not increase in duration, intensity or frequency
“Show” present “Show” absent
Accompanied by cervical changes
Not accompanied by cervical changes
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Modified Modified WHO WHO PartographPartograph
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Filling a Partograph
• Identification data– Name– Age,– Parity, – Date and time of
admission– Registration number;– Time of rupture of
membranes.
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Fetal monitoringFetal monitoring
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Fetal monitoring
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LIQOUR
I Membranes intact
C Clear liqour
M Meconium stained liqour
B Blood stained liqour
MOULDING
+ sutures apposed
++ sutured overlapped, reducible
+++ sutures overlapped, irreducible
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Plotting a partographPlotting a partograph
Interventions– Mention dose, route and
time of administration of any drug
– Mention the food items and liquids consumed
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Maternal vital signs
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Progress in labourProgress in labour Regular contractionsRegular contractions < 20 sec,< 20 sec, 20-40 sec,20-40 sec, > 40 sec> 40 sec
Dilatation of cervix –at least 1cm per hour Dilatation of cervix –at least 1cm per hour (follows alert line)(follows alert line)
- - chart aschart as XX
Descent of presenting part in fifths Descent of presenting part in fifths paplablepaplable
- - chart aschart as OO
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Plotting a partographPlotting a partograph
Labor• Begin plotting in active labor• Cervical dilatation > 4 cms• Repeat P/V after 4 hours and plot the cervical dilatation
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Progress of Labor
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ALERT and ACTION linesALERT and ACTION lines
• Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour.
• Moving to the right or the alert line may require referral to hospital for extra vigilance
• Action line: Parallel and 4 hours to the right of the alert line. A lag time of 4 hours between a slowing of labour and the need for intervention.
• When Action line is reached this is the critical line at which specific management decisions must be made
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Note that the first plot Note that the first plot on the partograph on the partograph
starts on the Alert Linestarts on the Alert Line
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xx
o o
Slow Slow progress progress in labourin labour
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Between alert and action linesBetween alert and action lines
• At lower level facility, the women must be transferred to At lower level facility, the women must be transferred to a higher level facility which can do a cesarean section, a higher level facility which can do a cesarean section, unless the cervix is almost fully dilatedunless the cervix is almost fully dilated
• Continue routine observations but prepare for transfer if Continue routine observations but prepare for transfer if neededneeded
• ARM may be performed if membranes are still intactARM may be performed if membranes are still intact
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Crossing the Action line
• Crossing of the Action line (the plotting moves to the right of the Action line) : indicates the need for intervention
• By the time the action line is crossed the woman should ideally have reached the FRU for the appropriate intervention to take place
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At or beyond action line:InterventionAt or beyond action line:Intervention
• Repeat full medical assessmentRepeat full medical assessment• Consider intravenous infusion / bladder catheterization / Consider intravenous infusion / bladder catheterization /
analgesiaanalgesia• OptionsOptions Augment with oxytocin by intravenous infusion only if there are Augment with oxytocin by intravenous infusion only if there are
no contraindicationsno contraindications Refer to a higher level facility Refer to a higher level facility Deliver by cesarean section if there is fetal distress or Deliver by cesarean section if there is fetal distress or
diagnosis is obstructed labourdiagnosis is obstructed labour
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Slow progress in labour ?Slow progress in labour ?
PowersPowers Inadequate contractions (dysfunctional labour)Inadequate contractions (dysfunctional labour)
PassagePassage Pelvis too small for baby (cephalopelvic disproportion Pelvis too small for baby (cephalopelvic disproportion
– CPD)– CPD)
PassengerPassenger Abnormal presentation or position ( e.g. transverse)Abnormal presentation or position ( e.g. transverse) Fetal abnormality (e.g. hydrocephalus)Fetal abnormality (e.g. hydrocephalus)
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PowersPowers
Slow progress often due to inadequate uterine Slow progress often due to inadequate uterine contractionscontractions
Restore normal progress by:Restore normal progress by:- rupturing membranes rupturing membranes - giving syntocinon by IV infusion where allowedgiving syntocinon by IV infusion where allowed- consider referral to FRUconsider referral to FRU
Reassess in 2 hoursReassess in 2 hours If no further progress REFER for CSIf no further progress REFER for CS
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Cephalopelvic disproportion (CPD)Cephalopelvic disproportion (CPD)
Malpresentation or MalpositionMalpresentation or Malposition
Fetal abnormalityFetal abnormality
Passage or Passenger:Passage or Passenger:
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Remember!Remember!
Slow progress may be due to any of the Slow progress may be due to any of the 3Ps3Ps
Augmentation with syntocinon may be Augmentation with syntocinon may be dangerous and cause rupture of uterusdangerous and cause rupture of uterus
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Slow progress in second stage:Slow progress in second stage:
Delay in descent of presenting partDelay in descent of presenting part
Delay in expulsionDelay in expulsion
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Slow progress in second Slow progress in second stage: Managementstage: Management
Review maternal positionReview maternal position Consider augmentationConsider augmentation If fetal head >2/5 palpable deliver by CS If fetal head >2/5 palpable deliver by CS
(Refer)(Refer) If fetal head < 1/5 palpable assist delivery If fetal head < 1/5 palpable assist delivery
by vacuum extraction (if avaliable)by vacuum extraction (if avaliable)
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If If slowslow progress becomes progress becomes nono progress and no action is progress and no action is
taken labour becomes taken labour becomes obstructedobstructed.
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RECAPRECAPWhen to start the partographWhen to start the partograph
Correct diagnosis of labourCorrect diagnosis of labour
Diagnosis and management of slow Diagnosis and management of slow progress in labour and ensure timely progress in labour and ensure timely referralreferral
Diagnosis of obstructed labourDiagnosis of obstructed labour
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