Partogram and Partogram and Obstructed Labour Obstructed Labour H. Gee MD, FRCOG H. Gee MD, FRCOG Consultant Obstetrician Consultant Obstetrician
Dec 26, 2015
Partogram and Obstructed Partogram and Obstructed LabourLabour
H. Gee MD, FRCOGH. Gee MD, FRCOGConsultant ObstetricianConsultant Obstetrician
Patterns of AberrancePatterns of Aberrance• Prolonged Latent Phase
– Slow cervical dilatation before Active Phase established– 20 hrs Nullips & 14 hrs Multips
• Primary Dysfunctional Labour– Progress< 1 cm/hr before Active Phase slope established– Incidence: Nullips 26%, Multips 8%
• Secondary Arrest– Cessation after normal active phase dilatation– Incidence: Nullips 6%, Multips 2%
PARTOGRAM- EAST AFRICA’S PARTOGRAM- EAST AFRICA’S GIFT TO THE WORLDGIFT TO THE WORLD
• Invented in Africa 1960’s
• Identify delay
• Identify increasing risk
• To determine place of delivery
• No comparative or controlled trials
• Common sense value recognised
Active Phase Cervicograms Active Phase Cervicograms - Philpott & Castle- Philpott & Castle
0 2 4 6 8 10
10
8
6
4
2
Alert L
ine
Cer
vica
l Dil
atat
ion
(cm
s,)
Time (hrs.)
WHO Partograph StudyWHO Partograph Study• Reduced incidence of prolonged
labour (8.3% vs 4.5%)
• Decreased need for augmentation (32% vs 13%)
• Increased spont vag del (74% vs 78%)
• Decreased caesarean section (9.8% vs 6.8%) *
* not Statistically Sig Lancet 1994343;1399-1404 (Nullips)
Partograph assessment by progress of labour and augmentation, by type of facilityPartograph assessment by progress of labour and augmentation, by type of facilityResults from Malawi auditResults from Malawi audit
Current situationCurrent situation
• Midwife tells you CS needed– Problems
• Is she right?• Do you understand the problem & implications.• Are there alternatives?
– e.g. forceps/vacuum in second stage
New situationNew situation
• You are team leader because of this course– When called
• You assess patient
– Power/passages /passenger– You improve care by whole team
COMPONENTS OF LABOURCOMPONENTS OF LABOUR
• The powersUterine contractions
• The passagesbony pelvis, and soft
tissues
• The passengerfetus
PowersPowers• Essential for good progress
– Cervical Dilatation– Flexion– Rotation
• Assessed by Palpation– Frequency 3-5 in 10 min.
• Augmented by Oxytocin & Amniotomy
The PassagesThe Passages
• Bony pelvis– Absolute cephalo-pelvic disproportion
• Kyphosis, Scoliosis, poliomyelitis, maternal dwarfism, ricketts, pelvic fracture.
• Soft tissue• fibroids, ovarian tumour, pelvic kidney, fat, cervical
stenosis, cervical cancer, vaginal\vulval atresia, vaginal septum.
The PassagesThe Passages
Disproportion
•Head Not Engaged– > 4/5 Palpable abdominally– VE: high head, caput+++, moulding+++
•CS essential
•PPH – Risk increased in Prolonged/Obstructed
labour
The Passenger-1The Passenger-1
– Large Fetus • Idiopathic
– Increasing Parity
• Pathologic macrosomia, – diabetes
• Fetal abnormalities– hydrocephalus– conjoined twins – hydrops fetalis
The Passenger-2The Passenger-2
• Malposition– Occipito-Posterior– Mento-Posterior
• Malpresentation• compound presentations• shoulder• brow• face
Signs of ObstructionSigns of Obstruction
• Maternal– Tachycardia– Pyrexia– Ketosis– Dehydration
• Fetal– Fetal heart rate abnormalities
TreatmentTreatment
• General– Re-hydration– Anti-biotics (if infection suspected)
• Specific– According to diagnosis
• Caesarean section
Caesarean Section in Caesarean Section in ObstructionObstruction
• Cesarean Section Problems– Impacted head – dis-impact before start– PPH
• IV sytno/ergometrine/misoprostol ready
– Bladder Injury• Leave catheter in for 10 days if blood stained
– Infection • IV antibiotics
Post deliveryPost delivery
• Reflective practise- team leader
• Critical incident review – WHY Poor Outcome?
• NO TRAINING• NO EQUIPTMENT• POOR COMMUNICATION• MATERNAL HEALTH VERY POOR