Using the partograph. Ilembula Lutheran Hospital Midwife, volunteer Minna Lämpsä FINLAND, Kuopio city. based on WHO guide

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1 Using the partograph Ilembula Lutheran Hospital Midwife, volunteer Minna Lämpsä FINLAND, Kuopio city. based on WHO guide

2 The Partograph is a graphical presentation of the progress of labour, and of fetal and maternal condition during labour Includes relevant details of the mother and fetus It`s the best tool to help detect whether labour is progressing normally or abnormally It warn s as soon as possible if there are signs of fetal distress or if the mother s vital signs deviate from the normal range can point to possible cephalopelvic disproportion before labour becomes obstructed Research studies have shown that maternal and fetal complications due to prolonged labour were less common when the progress of labour was monitored by the birth attendant using a partograph For this reason, you should always use a partograph while attending a woman in labour

3 The Partograph increases the quality and regularity of observations made on the mother and fetus serves as a one-page visual summary of the relevant details of labour has been used in a number of countries has been shown to be effective: preventing prolonged labour reducing operative intervention improving the neonatal outcome

4 what is to be noted in partograph fetal heart rate amniotic fluid moulding cervix dialtion descent of fetal head hours/running time contractions per 10 min Oxytocin U/L, drops/min Drugs and iv-fluids given Vital signs: Pulse, Blood Press Temperature Urine: protein, acetone, volume Partogarm needs to be filled in REALTIME, not after delivery

5 Fetal well-being record fetal heart rate for 1 minute every minutes during and after contraction in the first stage, and every 5 minutes in the second stage normal heart rate (100) (180) beat per minute If there are fetal heart rate abnormalities change mother`s position. The pressure to the cord may relief after that give instructions of good breething techniques Empty the bladder sustaine heart rate for 10 minutes suspect fetal distress and refer urgently to the doctor, unless the labour is progressing fast and the baby is about to be born If abnormalities are noted, urgent delivery can be considered

6 Amniotic fluid=liquor: I = membranes intact C = membranes ruptured, clear fluid M = meconium-stained fluid B = bloodstained fluid A= absent (water is not shown) Thick meconium suggests fetal distress, and closer monitoring of the fetus is indicated Check every 30 minutes

7 Normal variations in moulding of the newborn skull, which usually disappears within 1 3 days after the birth. Moulding Palpate and estimate how how fetal skull feels with your fingers and also the fetus head presentation 0 = bones are separated and sutures can be easily felt + 1 = bones are just touching each other + 2 = bones are overlapping but can be reduced + 3 = bones are severely overlapping Up to +2 occipitoparietal moulding may be normal

8 Moulding Swelling=caput succadaneum is more likely to form during a long or hard delivery It is more common after the membranes have broken. This is because the fluid in the amniotic sac is no longer providing a cushion for the baby's head It doesn t cause damage to the brain or the bones of the cranium or doesen`t automatically indicate to do cesarean section It can sometimes cause jaundice to the newborn

9 Vaginal examination: o Cervix (cm) Plot X o Descent of Head (Plot O) Spinaline assess cervical dilatation descent of the fetal head and moulding of skull bones In every 4 hrs or more frequent if it`s needed(severe pain, urge to push, fetal heart beat abnormalities)

10 Descent of the fetal head Is plotted using O as the symbol the fetal skull height is compared with the pelvic spina level

11 Table 4.1 Corresponding positions of the station of the fetal head (determined by vaginal examination) and the record of fetal descent on the partograph. Corresponding positions of the station of the fetal head (determined by vaginal examination) and the record of fetal descent on the partograph. Station of fetal head Corresponding mark on the partograph 4 or or SPINALINE

12 Good uterine contarctions are necessary for good progress of labour Record every 30 minutes How many and how longlasting contractions in 10 minutes Scale 1-5 If 2 contraction are felt in 10 min, shade two squares Mark with dots, Diagonal lines or solid shading

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14 Oxytocin It`s always Doctor`s order If it`s needed to have better contractions It may been needed if labour isn`t progressin If contractions get weaker during labour because of exhaustion, dehydration, infection etc must be very accurate when dosing! Record: the amount (in units) of oxytocin per volume of IV fluids 5 IU in 500ml of Natriumklorid 0,9% mix the drug well with the solution before attaching the infusion hose the number of drops per minute Start with 4 drops per minute Dose can be raised in every 30 min for 4 drops per minute till you get good lasting contarctions in every 3-4 minutes The maximum dose is 30 drops per minute without previous uterine scar every 30 minutes when used

15 Natural ways to help labour progress and stimulate oxitocin secretion: Walking/standing/different movements/positions stimulate nipples with hand acupressure Enough of fluids and food relaxing and good breething tecnique

16 Drugs given and IV fluids A woman in labour loses body fluid quickly and she also uses up a lot of energy During the 1 stage of labour, mother should drink at least 1 cup every hour of a high calorie fluid such as tea, soft drinks, soup, or fruit juice If she does not drink enough, she may get dehydrated (not enough water in the body) This make labour much longer and harder and make a woman feel exhausted

17 Signs of dehydration include: Dry lips Sunken eyes Loss of stretchiness of skin Mild fever (up to 38 C) Fast, deep breathing (more than 20 breaths a minute) Fast, weak pulse (more than 100 beats a minute)

18 Mother`s vital signs: Pulse: record once in every hour and mark with a dot ( ) Blood pressure: record every 4 hours and mark with arrows unless the patient has a hypertensive disorder or preeclampsia, in which case record every 30 minutes

19 o Temperature record at last in every 4 hours or more often Fever must be treated because it increases the risk for fetal asphyxia! o Fluids po or IV and paracetamol 1 g po/iv Urine, ketones and volume: Urine output is recorded every time urine is passed ketones and volume: ideally record every time urine is passed

20 Encourage the woman to urinate at least once every 2 hours during labour If bladder is full contractions may get weaker and labour longer cause Pain problems with pushing out the fetus and placenta bleeding after childbirth

21 Example of a normal labour progress

22 Obstructed labour

23 Obstructed labour Labour is considered obstructed when the presenting part of the fetus cannot progress into the birth canal, despite strong uterine contractions

24 Determinats and trends in obstructed labour the probability to have obstructer labour is greater if the mother is short or has a history of previous difficult labor The small size of a mother (small pelvis), previous caesaren section and nulliparity can increase a risk of dystocia none of these factors have adequate positive predictive value as screening tools It is thus almost impossible to predict the occurrence of obstructed labour before the onset of labour Labour must therefore be monitored carefully and systems to manage or refer complications must be available Trends in obstructed labour are difficult to assess because studies may have used different definitions

25 Obstructed labour The most frequent cause of obstructed labour is cephalo-pelvic disproportion - a mismatch between the fetal head and the mother's pelvic brim The fetus may be large in relation to the maternal pelvic brim, such as the fetus of a diabetic woman the pelvis may be contracted, which is more common when malnutrition is common Some other causes of obstructed labour may be malpresentation or malposition of the fetus (shoulder, brow or occipito-posterior positions) In rare cases, locked twins or pelvic tumours can cause obstruction

26 Obstructed labour can cause Maternal complications include intrauterine infections following prolonged rupture of membranes trauma to the bladder and/or rectum due to pressure from the fetal head or damage during delivery ruptured uterus with consequent haemorrhage, shock or even death Trauma to the bladder during vaginal or instrumental delivery may lead to stress incontinence the most severe and distressing long-term condition following obstructed labour is obstetric fistula - a hole which forms in the vaginal wall communicating into the bladder (vesico- vaginal fistula) or the rectum (recto-vaginal fistula) or both In developing countries, fistulae are commonly the result of prolonged obstructed labour and follow pressure necrosis caused by impaction of the presenting part during difficult labour In the infant, neglected obstructed labour may cause asphyxia leading to stillbirth, brain damage or neonatal death

27 Conclusions Partograph is a tool which is only as good as the nurse/midwife who is using and filling it it is a matter of honour to take care for mother and childbirth and strive to make every effort to allow normal vaginal delivery. If it isn`t possible, well filled partograph helps to identify abnormalities during childbirth and to intervene in sufficient time

28 Thank you!