Partograph

Partograph

Partograph

Itis a visual/graphical representation of related values or events over the course of labor. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs. A concept of recording the progress of labour on a chart was started first by Freidman in 1954 who used graphic records of cervical dilatation in labour. This was further developed and extended by philpot in1972.

The WHO partograph has been modified 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.

PURPOSE

To provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly and treated accordingly

A decision-making tool rather than only a record. Start when dilation reaches 4 centimeters.

Use through out labor to help:

Evaluate fetal and maternal well-being

Assess progress of labor

Identify problems

Guide decision-making for care

Provide a record of findings

Advantages

A single sheet of paper represents a dynamic documentation of the events in labour as they unfold in time.

It provides a record of parameters denoting maternal and fetal well being.

It can predict deviation from duration of labour so appropriate steps could be taken in times

Saves working time of staff against writing labours notes in long hand.

It facilitates handover procedure of staffs.

Improves perinatal outcome

Avoindance of difficult obstetric interventions.

No need to record labour events repeatedly.

Gives clear picture of normality and abnormality in labour.

Educational value for all staff.

Indication of using partograph:

Partograph must be used when labour is expected to be normal.

Before using partograph check for any complication of pregnancy which required immediate action.

Contraindication for using partograph:

Antepartum haemorrhage

Diagnosed CPD

Severe pre-eclampsia and eclampsia

Fetal distress

Severe anemia

Multiple pregnancy

Mal presentation

Premature labour

Obstructed labour

Principles of plotting partograph

Active phase of labour commence at 4 cm cervical dilation.

The latent phase of labour should last not longer than 8 hours.

During active labour, the rate of cervical dilatation should not be slower than 1cms/hours.

A lag time at 4 hours between a slowing of labour and the need for intervention is unlikely to compromises the fetus or the mother and avoid unnecessary intervention.

PV examination should be performed as infrequently as it is compatible with safe practice.

It is better to use a partograph with pretest line, although too many lines may added further confusion.

Components of Partograph

A- Basic information (Patients identification)

B- Fetal heart rate

C- Amniotic membrane and moulding

D- Descent of fetal head

E- Cervical dilatation

F- Uterine contraction

G- Oxytocin drip

H- Drug and other intravenous fluid

I- Not used

J- Maternal condition(vitals sign)

K- Urine analysis

Patient basic information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes and time of onset of true labour pain.

Fetal heart rate: The rate of the fetal heart indicates the state of fetus inside the uterus. Record every half hour. Plot one dot (.) in the line at the level of the heart rate indicated in figure on left hand. Each squire in the graph indicates half hour as fetal heart is recorded every half hour. The recording is more frequent as the labour progresses. The FHR recording is done just after uterine contraction is over. The average baseline FHR should be between 100-180 beats per minute. If there are fetal heart rate abnormalities (180 beats per minute) suspect fetal distress.

Amniotic fluid: State the state of membranes whether it is (+) or (-) and if it is ruptured record the colour of amniotic fluid at every vaginal examination and time of rupture. The state of liquor can assist in assessing fetal condition after the rupture of membranes. Normally the amniotic sac contains whitish watery fluid, occasionally with flakes of vernix caseosa. It may be green, Yelloish green in colour when stained with meconium.Recording is done as:

I: membranes intact;

C: membranes ruptured, clear fluid;

M: meconium-stained fluid;

B: blood-stained fluid.

A: Liquor not seen or abscent.

Moulding: Moulding is an important finding as to know how well the pelvis will accommodate the fetal head. It is the alteration of the shape of the forecoming head that takes place during its passage through the birth canal or It is a state of reduction or loss of space between skull bones. Presence of increased moulding of the head in the pelvis indicates CPD. Presence of caput makes it difficult to assess moulding but that is itself is sign of CPD.

Recording of degree of moulding

0: Bones are separated

1: sutures apposed ;(+)

2: sutures overlapped but reducible ;(++)

3: sutures overlapped and not reducible. (+++)

Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm.The graph consists of homogenous squires, ten square vertically, each squire indicate one centimeter of cervical dilatation. There are 24 squares spread horizontally, each square indicating one hour each. The crosses in the graph are joined by a continuous line. The climbing tendency of this line normally lies on the middle of the graph. When this line crosses the midline take this as warning to be caution or alert.

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.

Action line: Parallel and 4 hours to the right of the alert line. Necessary action should be taken if it crosses the action line.

Note:

Remember, first cervical dilatation should be plotted on alert line.

Subsequent cervical dilatation is plotted on the basis of the time of first cervical dilatation.

Descent assessed by abdominal palpation: Refers to the part of the 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.

At 5/5, the 5 parts of the head is palpable above the symphasis pubis or brim in which the both sinciput and occiput is palpable at same level if the head is deflexed and sinciput is higher than occiput in well flexed head.

At 4/5, sinciput high and occiput easily felt just above the pelvic brim.

At 3/5 sinciput easily felt and occiput felt at pelvic brim.

At 2/5, sinciput felt and occiput just felt.

At 1/5 sinciput felt, occiput not felt.

At 0/5 no of the head is palpable

Hours: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated).

Time: Record actual time according to the hours of active phase of labour started.

Uterine Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. The squires in the vertical columns are shaded according to the duration and intensity. The graph has five squires vertically and 48 squires horizontally.Each squire represents one contraction lasting 10 seconds.

In normal labour, contractions usually become more frequent and last longer as labour progresses.

Shade the square according to duration of contractions as follows:

Less than 20 seconds:

Between 20 and 40 seconds:

More than 40 seconds: