Partograph and labor dystocia for undergraduate

Partograph Partograph

PartographPartograph A partograph is a graphical record of the observations made of a women in labor

For progress of labor and conditions of the mother and

the fetus

History Of PartogramHistory Of PartogramFriedmans partogram

Cervical dilatation and fetal station against time in hours from onset of labouryielded the typical sigmoid or S shaped curve

ObjectivesObjectives early detection of abnormal progress of a labour

prevention of prolonged labour

Recognize cephalo pelvic disproportion long before obstructed labour

Assist in early decision on transfer augmentation or termination of labour

Early recognition of maternal or fetal problems

Components of the partographComponents of the partographPart 1 fetal condition ( at top )Part 2 progress of labour ( at middle )Part 3 maternal condition ( at bottom )

Mother information

Fetal well-being bull Fetal heart ratebull Character of liquorbull Moulding

Labour progress bull Dilatation

bull Descent

bull Uterine contraction

Medicationsbull Oxytocinbull Pain relief (eg pethidine)

Maternal well-being bull BP Pulse Temperaturebull Urine ndash albumin glucose acetonebull Urine output

Part 1 Fetal condition Part 1 Fetal condition Recording fetal heart rateRecording fetal heart rate

Membranes and liquorMembranes and liquor

Dilated cervix with bag of fore water

I intactC clearM muconiumB blood stained

Molding the fetal skull bonesMolding the fetal skull bones Increasing molding with the head high in the pelvis is an ominous

sign of Cephalopelvic disproportion separated bones sutures felt easilyhelliphelliphellipO bones just touching each otherhelliphelliphelliphelliphellip+ overlapping bones helliphelliphelliphelliphellip helliphelliphelliphellip++ severely overlapping bones ( notable ) helliphellip+++

Part 2 ndash progress of labourPart 2 ndash progress of labour Cervical dilatation it is divided into a latent phase and an

active phase Descent of the fetal head Uterine contractions

Cervical dilatationCervical dilatation It is the surest way to assess progress of labour

latent phase latent phase

Starts from onset of labour until the cervix reaches 3 cm dilatation

lasts 8 hours or less

Contractions at least 210 min contractions

each lasting lt 20 seconds

Active phase Active phase

The cervix should dilate at a rate of 1 cm hour or faster

Contractions at least 3 10 min each lasting lt 40 seconds

Alert line ( health facility line )Alert line ( health facility line )

The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm hour

Moving to the right or the alert line means referral to hospital for extra care

Action line ( hospital line )Action line ( hospital line )The action line is drawn 4 hour to the right

of the alert line and parallel to itThis is the critical line at which specific

management decisions must be made at the hospital

When labor goes from latent to active phase plotting of the dilatation is immediately transferred from the latent phase area to the alert line

Abnormal labor progress Abnormal labor progress

Descent of the fetal headDescent of the fetal head

The rule of fifth BY abdominal examination

Assessing descent of the fetal PVAssessing descent of the fetal PV 0 station is at the level of the ischial spine 0 station is at the level of the ischial spine

Recording uterine contractionRecording uterine contraction

PART 3Recording of maternal PART 3Recording of maternal conditioncondition

--

Abnormal labor and DystociaAbnormal labor and Dystocia

One of the main functions of the partograph is to detect early deviation from normal progress of labor

0

2

4

6

8

10

12

2 4 6 8 10 12 14 16

Latent phase Active phase

2nd stage1st stage

max slope

acceleration

dec

Time (hours)

Cervical dilatation (cm)

Friedman labor curve in nulliparous

Normal progress in labor Normal progress in labor

A prolonged latent phaseB prolonged active phaseC arrest active phase

Abnormal progress in labor

Prolonged latent phaseProlonged latent phase

1048698 Nulliparas

Multiparas

prolonged

gt20 hr

gt 14 hr

Normal average

64 hr

48 hr

Management Management Prolong Latent Phase Prolong Latent Phase

ndash Simple analgesiandash Encourage mobilizati on ndash Reassurancendash ARM and oxytocin will cause poor progress

later

Protraction disordersProtraction disorders

1048698 Nulliparas

Multiparas

Descent

lt10 cmh

lt20 cmh

Dilation

lt12 cmh

lt15 cmh

Average

8hr

5hr

Arrest disorderArrest disorder

1048698 Nulliparas

Multiparas

Descent

gt2h

gt1h

Dilation

gt2h

gt1h

Causes of Protraction disordersCauses of Protraction disorders

1048698

minor malpositions such as occiput posterior

improperly administered conduction anesthesia excessive sedation

Fetopelvic disproportion

Treatment of protraction and Treatment of protraction and arrest disorderarrest disorder

Cesarean section is indicated in the presence of confirmed fetopelvic disproportion

In the absence of fetopelvic disproportion support and close observationoxytocin augmentation

Critical Factors

Psyche Powers

Passenger

Passageway

Dysfunctional Labor is related to Abnormalities of the Critical Factors

Psychology of birthPsychology of birth

The progress of labor and birth can be adversely affected maternal fear and tension

Norepinephrine and epinephrine may stimulate both alpha and beta receptors of the myometrium and interfere with the rhythmic nature of labor

Anxiety can also increase pain perception and lead to an increased need for analgesia amp anesthesia

Characteristics of theCharacteristics of the powerpower

Intensity is greater in the fundus Average 24mmHg Well synchronized Frequency Duration 60s regular Rhythm and force Basal resting pressure 12-15mmHg

Fetal monitoringFetal monitoring

Friedmanrsquos GraphFriedmanrsquos GraphHypotonic Uterine ContractionsHypotonic Uterine Contractions

Prolonged active phase

Normal Curve

Therapeutic InterventionsTherapeutic Interventions

ndash Ambulation

ndash Nipple Stimulation --release of endogenous Pitocin

ndash Enema--warmth of enema may stimulate contractions

ndash Amniotomy--artificial rupture of the membranesndash Augmentation of labor with Pitocin

AmniotomyAmniotomy Amniotomy is the artificial rupture of the amniotic

sac with a tool called the amniohook 1-Check the fetal heart tones

ndash Assess color odor amountndash Provide with perineal carendash Monitor contractionsndash Check temperature every 2 hours

Hypertonic and uncoordinated Hypertonic and uncoordinated dysfunctiondysfunction

Resting tone

Dyssynchronous

Frequent intense contraction

Constriction ring

Tocolysis

Decrease oxytocin

Cesarean section

Sedation

Friedmanrsquos GraphFriedmanrsquos GraphHypertonic Uterine ContractionsHypertonic Uterine Contractions

Prolonged latent phase

Cephalopelvic Disportion (CPD)Cephalopelvic Disportion (CPD)

Causesndash Large baby or small pelvisndash Usually diagnosed when there is an arrest in descent

Symptomsndash Station remains the same does not descend

Treatmentndash Usually do a cesarean delivery if cause is pelvisndash Utilize other measures such as forceps vacuum

extraction episiotomy

Pelvi- Latin word pelvis (basin)

Metron - Greek word for measure

Pelvimetry means to measure the pelvis

Three level of bony pelvisThree level of bony pelvis

Measuring diagonal conjugate

Insert two fingers into the vagina until they reach the sacral promontory

The distance from the sacral promontory to the exterior portion of the symphysis is the diagonal conjugate and should be greater than 115 cm

Unengaged fetal head

bull Feel the ischial spines for their relative prominence or flatness

bull Ischial prominence narrows the transverse diameter of the pelvis

bull Feel the pelvic sidewalls to determine whether they are parallel (OK) diverging (even better) or converging (bad)

bull Narrow sacrosciatic notch

Measure the bony outlet by pressing your closed fist against the perineum

Greater than 8 cm bituberous ( or transverse outlet) is considered normal

Narrow pubic archlt90