2a intra partum care

1

Intrapartum Care & Partograph

Session 2a

Care during labor and delivery

Maternal Health DivisionMinistry of Health & Family

WelfareGovernment of India

BEMoC - Presentation 2 (a)

INTRAPARTUM CARE & PARTOGRAPH



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Session Objectives

To learn about: How to conduct a normal labour Identify and manage complications during

labour How to plot a partograph




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TRUE & FALSE LABOUR PAINS

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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Stages of labour

First stage: From onset of labor till full dilatationof cervix Latent Phase

• Cervix < 4 cms• Contractions are weak• Less than 2 contractions per ten minutes

Active phase• Cervix > or = 4 cms• Contractions >3 per 10 min lasting 45 - 50 sec • Rate of dilatation 1cm / hour or more• Descent present




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Points to Remember

Examine abdomen before vagina Do not shave perineum Wash hands,clean gloves,explain to the female

about PV If bleeding PV - PV not to be done Supine position with her legs flexed and apart




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Cervical effacement Cervical dilatation in cms Presenting part Station and position of presenting part Status of membranes Color of liquor

During PV examination




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Supportive Care during Labour

Keep woman informed of her progress Maintain privacy Encourage her to keep herself clean, wash

perineum Enema NOT ROUTINE: only if needed Empty bladder frequently




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Supportive Care during Labour

Presence of second person or birth companion

Woman to be ambulatoryWoman free to choose any position

during labor & deliveryHold her hand, massage backPlenty of fluids, light fat free food




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Non Pharmacological pain relief

Calm and gentle voice Offering encouragement, reassurance and

praise Relaxation techniques deep breathing

exercises and massage Assisting the woman in voiding urine and in

changing her position




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Stages of labour

Second stage: From full dilatation of cervix till

delivery of baby Full cervical dilatation Bulging thinned out perineum Gaping anus and vagina Head visible at the perineum




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Stages of labour

Third stage: From delivery of baby to delivery of placenta

Fourth stage: For 2 hrs after delivery of the baby




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Monitoring of first stage of labour –Latent phase

Monitor every 1/2 hour• Contractions:

Frequency: How many contractions in 10 min Duration: Each lasting for how many seconds

• Fetal Heart Rate (FHR) Monitor the following every 4 hours: Temperature, pulse,

blood pressure Record time of rupture of membranes and color of

amniotic fluid. Emergency signs: Difficulty in breathing, shock, vaginal

bleeding




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Monitoring of First Stage of Labour

In Latent Phase After 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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Monitoring of first stage of labour – Active phase

Monitor the following every 30 minutes: Maternal pulse, uterine contractions, FHR Look for presence of -

• Meconium or blood stained liquor or cord prolapse

Monitor the following every 4 hours:• Cervical dilatation (in cm) by P/V• Temperature• Blood pressure




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Monitoring of First stage of Labour

In Active Phase Never leave the woman alone Monitor intensively using Partograph Refer immediately if no progress




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Partograph

What is a partograph? Graphic recording of the progress of labor

& condition of mother and fetus Labor record , thus reduces paper work Tool to identify complications of labor and

make timely referrals




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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 Condition Count fetal heart

rate every half hour Count for one full

minute, immediately following a uterine contraction

Fetal distress: FHR <120

beats/minute or >160 beats/minute

Arrange for referral




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Record status of membranes and

amniotic fluid in Partograph as follows: Membranes intact (mark ‘I’) Membranes ruptured (mark ‘R’) Clear liquor (mark ‘C’) Meconium stained liquor (mark ‘M’)




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Plotting a partograph

Labor Begin plotting in active

labor Cervical dilatation > 4

cms and > 2 contractions / 10 minutes

Plot the initial finding. Note the time.

Repeat P/V after 4 hours and plot the cervical dilatation




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Plotting a Partograph

Chart the contractions every half an hour Number of contractions in 10 mins Duration in seconds.

• Less than 20 seconds • Between 20 and 40 seconds ////• More than 40 seconds




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Maternal Condition Record maternal pulse

every half hour and mark with a dot ( . )

Record maternal BP every 4 hours using a vertical arrow, with upper end signifying systolic BP and lower end diastolic BP

Record the temperature every 4 hours and note on temperature graph




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Interventions Mention dose, route

and time of administration of any drug

Mention the food items and liquids consumed




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If Alert line is crossed (the plotting moves to the right of the alert line) it indicates abnormal labour : prolonged/ obstructed labour

Note the time Refer patient to FRU Send partograph with

patient




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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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What are the indications for referral to FRU – on the basis of partograph ?

FHR is <120 beats / min or > 160 beats / min Meconium and /or blood stained amniotic fluid When cervical dilatation plotting crosses the

alert line (moves towards the right side of the alert line)

Contractions not increasing in duration, intensity and frequency (e.g. < 2 contractions lasting for < 20 sec in 10 min)




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Monitoring of second stage of labour

Monitor the following every 5 minutes Frequency,duration and intensity of

contractions FHR Perineal thinning and bulging Visible descent of foetal head during

contractions Presence of any signs indicating an

emergency




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Abdominal palpation

Watch for signs of imminent deliveryGaping of vulva Thinning and bulging of perineumPouting of anusHead of the baby seen at vulva

Encourage the woman to push duringcontractions when she has an urge to do sowhile taking deep breaths




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Supportive management during second stage

Any position woman is comfortable: dorsal lithotomy, tanding, sitting, squatting.

Encourage bearing down when has urge to push at full dilatation

Discourage bearing down before the cervix is fully dilated

Do not ask her to hold breath Avoid ironing (sweeping and stretching) the

perineum




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2nd stage management (contd...)

OXYTOCICS: not routinely recommended insecond stage.

EPISIOTOMY: not routine complicated vag. Delivery (malpresent) h/o third/fourth degree perineal tears foetal distress Instrumental/assisted delivery.




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2nd stage management (contd...)

Encourage rapid breathing with mouth open. Hydration- oral / IV fluids DO NOT apply fundal pressure 5 clean’s- surface, hands, cord tie, blade,

cord stump Prepare for active mgmt. 3rd stage




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Delivery of Head

Ensure a controlled delivery of the head by keeping one hand gently on the head and other supporting the perineum

Feel gently around the baby’s neck for presence of umbilical cord

If it is loose around the neck, deliver the baby through the loop of the cord, or slip the cord over the baby’s head

If it is tight around the neck, doubly clamp and cut in between




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Delivery of shoulders and rest of the body

Wait for the spontaneous rotation and delivery of the shoulders. This usually happens within 1-2 minutes

Apply gentle pressure downwards to deliver the top (anterior) shoulder

Then lift the baby up, towards the mother’s abdomen, to deliver the lower (posterior) shoulder

Deliver one shoulder at a time Rest of the baby’s body follows smoothly Note the time of birth




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Immediate postpartum care

Fourth stage: first one hr after delivery. After placental delivery- check uterus well

contracted Examine perineum, lower vagina and vulva for

tears. Estimate the blood loss Clean the perineum Sanitary napkins




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Immediate postpartum care

Dispose placenta in correct, safe and culturally appropriate manner.

Keep mother and baby together- encourage early breastfeeding.

Encourage woman to eat,drink and rest. Encourage woman to pass urine. Do not discharge the woman before 24 hours

after delivery.




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Postpartum

Nutrition: advise to eat greater amount of foods Exclusive breastfeeding and rooming in Contraception: advise regarding birth spacing

or limitation. Registration of birth Postpartum visits- first at 7-10 days. Second at

6 weeks




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Key Messages

Let the woman choose a comfortable position during labour and delivery

Maintain a partograph




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Moulding

Sutures apposed +

Sutures overlapped but reducible 2+

Sutures overlapped but not reducible 3+

Symbols

Cervix x

Head O

Breech w

Fetal heart rate .

Amniotic fluid

Membranes intact I

Membranes ruptures, clear fluid C

Meconium stained fluid M

Blood stained fluid B

1 WHO Managing complications in pregnancy and childbirth

PARTOGRAPH

Usual frequency of examination

Vaginal examination 4 hourly

Fetal Heart Rate ½ - ¼ hourly

Descent: Abdominal palpation1Descent: Abdominal palpation1

Contractions: Palpate abdomen (uterine fundus) over 10 min

Mild <20 seconds

Sutures overlapped but reducible 20-40 seconds

Sutures overlapped but not reducible >40 seconds




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Partograph Case 1

Name: Mrs KA

Hospital No.: 462432 XY

Age (Years): 20

Parity: Para 0 +0

Gestational age (Weeks): 38

TimeCervix (cm)

Membranes/Liquor

Lie PresentationFHR

(/Min.)Moulding Descent

Contractions(/10 Min.)

9am 2cm Intact longitudinal Cephalic 140 o 5/52 (<20

seconds)

History

• Lower abdominal pains• No drainage of liquor

Time 9am

Pulse rate (/Min.) 90

Blood pressure (mmHg) 120/80

Temperature (o C) 37.1o

Questions

• What actions will you take?

• How will you look after this woman?




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Partograph Case 2

Name: Mrs AD


Age (Years): 18

Parity: Para 2+0


Time Cervix (cm)

Membranes/Liquor

Lie Presentation FHR (/Min.)

Moulding Descent Contractions(/10 Min.)

4pm 4cm Intact longitudinal Cephalic 144 0 3/5 3 (35sec. each)

8pm 8cm Clear longitudinal Cephalic 146 0 2/5 4 (45 sec. each)

History

• Lower abdominal pains for 2 hours• Drainage of liquor for 1 hour

Time 4pm 8pm

Pulse rate (/Min.) 88 90

Blood pressure (mmHg) 120/70 120/70

Temperature (o C) 37o 37o

Questions• What actions will you take

at 4pm?




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Partograph Case 2

Name: Mrs AD


Age (Years): 18

Parity: Para 2+0


Time Cervix (cm)

Membranes/Liquor



4pm 4cm Intact longitudinal Cephalic 144 0 3/5 3 (35sec. each)

8pm 8cm clear longitudinal Cephalic 146 0 2/5 4 (45 sec. each)

History

• Lower abdominal pains for 2 hours• Drainage of liquor for 1 hour

Time 4pm 8pm

Pulse rate (/Min.) 88 90

Blood pressure (mmHg) 120/70 120/70

Temperature (o C) 37o 37o

Questions• What actions will you take

at 4pm?• What actions will you take

at 8pm?




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Partograph Case 3

Name: Mrs DG


Age (Years): 19

Parity: Para 0 +1


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)

Moulding

Descent


6am 5cm Intact membranes longitudinal Cephalic 140 0 4/5 3 (40sec. each)

10am 5cm Artificial rupture of membranes: clear

longitudinal Cephalic 146 0 3/5 2 (20sec. each)

12pm (noon)

8cm clear Longitudinal

Cephalic 140 0 2/5 2 (10 sec. each)


History

• Lower abdominal pains for 10 hours• No drainage of liqour

Time 6am 10am 12pm 2pm

Pulse rate (/Min.) 80 84 88 92

Blood pressure (mmHg) 130/70 130/70 140/70 140/70

Temperature (o C) 37.3o 37 37.5 37.5

Questions• What actions are

required?• When would the next

examination be?




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Partograph Case 3

Name: Mrs DG


Age (Years): 19

Parity: Para 0 +1


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)

Moulding

Descent





12pm (noon) 8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec. each)


History





Temperature (o C) 37.3o 37 37.5 37.5

Questions• Comment on the

partograph. What actions are required?

• When would the next examination be?




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Partograph Case 3

Name: Mrs DG


Age (Years): 19

Parity: Para 0 +1


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)

Moulding

Descent





12pm (noon) 8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec. each)


History





Temperature (o C) 37.3o 37 37.5 37.5



• When would the next examination be?




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Partograph Case 3

Name: Mrs DG


Age (Years): 19

Parity: Para 0 +1


Time Cervix

(cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)

Moulding

Descent





12pm (noon)

8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec. each)


History





Temperature (o C) 37.3o 37 37.5 37.5






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Partograph Case 4

Name: Mrs HA


Age (Years): 16

Parity: Para 0 + 0


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)


10am 4cm Spontaneous rupture, clear

L Cephalic 150 1 + 3/5 3 (30 sec. each)

2pm 6cm Blood stained L Cephalic 156 2 + 3/5 4 (40 sec. each)

4pm 6cm Meconium stained L Cephalic 164 3 + 3/5 4 (45 sec. each)

History

• Labour at home for 6 hours• Membrane ruptured 4 hours before admission

Time 10am 2pm 4pm

Pulse rate (/Min.) 80 86 92

Blood pressure (mmHg) 120/70 130/70 130/70

Temperature (o C) 37 37.2 37.2

Questions• Plot the information on a partograph.• What action will you take?• When would you perform the next

vaginal examination?




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Partograph Case 4

Name: Mrs HA


Age (Years): 16

Parity: Para 0 + 0


Time Cervix (cm)

Membranes/Liquor






4pm 6cm Meconium stained


History


Time1 10am 2pm 4pm




Questions• Comment on the partograph.• When would you perform the next

vaginal examination?

Maternal and Newborn Health Unit Liverpool School of Tropical MedicineLSTM/RCOG Life Saving Skills –Essential (Emergency ) Obstetric Care and

Newborn Care




49

Partograph Case 4

Name: Mrs HA


Age (Years): 16

Parity: Para 0 + 0


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)





4pm 6cm Meconium stained L Cephalic 164 3 + 3/5 4 (45 sec. each)

History


Time 10am 2pm 4pm




Questions• Comment on the partograph.• What action will you take in a

BEOC and CEOC health facility

Maternal and Newborn Health Unit Liverpool School of Tropical MedicineLSTM/RCOG Life Saving Skills –Essential (Emergency ) Obstetric Care and

Newborn Care




50

Partograph Case 5

Questions• You are called. What would you

do? • When will you do another vaginal

examination?

Name: Mrs SA


Age (Years): 24

Parity: Para 3+1


Time Cervix (cm)

Membranes/Liquor

Lie Presentation

FHR (/Min.)


10am 4cm Spontaneous rupture 2 hours ago, clear

L Cephalic 140 0 3/5 3 (30 seconds)

2pm 8cm Clear L Cephalic 156 1+ 3/5 3 (40 seconds)


History

• Lower abdominal pains 3 hours• Drainage of liquor 2 hours

Time 10am 2pm 4pm



Temperature (o C) 37o 37o 37




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Partograph Case 5

Questions• Comment on the partograph.• What action would you take?

Name: Mrs SA


Age (Years): 24

Parity: Para 3+1


Time Cervix (cm)

Membranes/Liquor







History


Time 10am 2pm 4pm







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Partograph Case 5

Questions• Comment on the partograph.• What action will you take?• What are the options for delivery?

Name: Mrs SA


Age (Years): 24

Parity: Para 3+1


Time Cervix (cm)

Membranes/Liquor







History


Time 10am 2pm 4pm







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Session 2a

Case Study No. …………….. 1-3

Page no……………………… 15-19

Answer to Case Study……… 125-127

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Thank you

2a intra partum care

Health & Medicine

normal labour

cervical dilatation

cms contractions

bleeding pv pv

femaleabout pv

position of presenting

onset of labor

minutes active phase