MANAGEMENT OF

LABOUR WITH

PARTOGRAM

OBJECTIVES

At the end of this session you are expected to be able to:

1. Define the partogram

2. Explain the importance of using partogram in labour.

3. Describe the principles that are used to design the partogram

4. Describe the principles of using the partogram at the basic and comprehensive health facilities.

5. Describe the protocol for labour management with the WHO partogram

What is a partogram

(partograph) ?

DefinitionThe partogram

Is a graph used in labour to monitor the parameters of progress of labour, maternal and fetal wellbeing, and treatment administration

PRACTICAL VALUE OF USING THE PARTOGRAM

Offers an objective basis for overtime monitoring the progress of labour, maternal and fetal wellbeing.

Enables early detection of abnormalities of labour

Prevention of obstructed labour and ruptured uterus.

PRACTICAL VALUE OF PARTOGRAM cont

Complications of obstructed labour and

ruptured uterus contribute up to 30% of

maternal deaths in some areas.

Proper use of partogram has proved so

useful in reduction of both maternal and

perinatal mortalities and morbidities

RECOMMENDATIONS ON THE USE OF PARTOGRAM

Based on the evidence-based reports on its effectiveness in monitoring of labour.

WHO

Recommends its use in all labour wards and for all women (WHO 1994)

Tanzania Its use is obligatory at all levels of obstetric care

PRINCIPLES USED TO DESIGN THE PARTOGRAM

The partogram depends on the principles that;

1. The latent phase should not last longer than 8 hours

2. The latent phase ends and active phase starts when the cervix is 3cm (4cm is sometimes used)

3. During active phase – the cervix should dilate at not less than 1 cm per hour

PRINCIPLES cont

4. A lag time of 4 hours is usually

acceptable the slowing of labour and the

need to intervene; this is the distance

between alert line and the action line.

PRINCIPLES OF USING THE PARTOGRAM

1. Basic health facilities Used to monitor labour which is expected to be

normal. Those with risk factors should already have been

referred. Referral is decided when the progress line of the

cervical dilatation deviates to the right of an alert line.

2. Health facilities with comprehensive EmOC. Used to monitor both high and low risk labour

PROTOCOL FOR LABOUR

MANAGEMENT WITH THE

WHO PARTOGRAM

EXCLUSIONS

Don’t complete the partogram in case of:

Prematurity (<34/40)

Cervical dilatation 9 -10 cm on admission

Elective CS

Emergency CS on admission

STARTING THE PARTOGRAM

1. Latent phase Contractions at least 2 in 10, lasting ≥ 20 sec

2. Active phase Contractions at least 1 in 10, lasting ≥ 20 sec

3. SRM but no contractions When oxytocin is started or when labour commences

4. Inductions At ARM ± oxytocin When induction is medical start when labour commences

(see 1 and 2) or membranes rapture.

DESIRED UTERINE CONTRACTIONS

The desired rates of uterine contractions in labour = 4 - 5 in 10 minute, each lasting 40-50 seconds.

It may be maintained at that rate

throughout 2nd and 3rd stage of labour

TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE UP TO ACTION LINE

Parameter

Ideal

in both phases

(hrs)

Minimum acceptable

Latent phase

Active phase

Vaginal examination 4 8 4Descent of head 4 8 4Contractions ½ 4 2Fetal heart beats ½ 4 1Temperature, PR, BP, urine 4 4 4

TIMING OBSERVATIONS IN LATENT PHASE AND ACTIVE PHASE

Vaginal examination may be carried

out more frequently in advanced first

stage 7+cm or if problems develop

MANAGEMENT OF LABOUR BETWEEN

ALERT AND ACTION LINES

Known as Alert or Referral zone

1. Health facilities with Basic EmOC

Transfer the woman to hospital unless the cervix is

almost fully dilated

ARM may be performed if membranes are still intact

and first stage of labour is advanced and delivery is

expected soon.

MANAGEMENT OF LABOUR BETWEEN

ALERT AND ACTION LINES

2. Health Facility with Comprehensive EmOC

Perform ARM at vaginal examination

Continue routine monitoring

Repeat vaginal examination 4 hrs or earlier if

delivery is expected sooner

Do not intervene or augment – unless

complications develop

MANAGEMENT OF LABOUR AT OR BEYOND THE

ACTION LINE

1. Full medical and obstetric assessment

2. Consider IV infusions/ catheterization/ analgesics (pethidine)

3. Options Perform CS - if fetal distress or obstructed labour or

operative vaginal delivery if in 2nd stage without severe fetal distress and/or obstructed.

Oxytoxin – if no contraindications Supportive therapy only – if satisfactory progress is

established and dilatation could be anticipated at 1cm/hr or faster.

FURTHER REVIEW - in cases continuing in labour

Vaginal exam after 2 hours, then in 2 more hours, then in 2 more hours

Failure to make satisfactory progress, measured as cervical dilatation of < 1cm/hr between these examinations, means delivery is indicated

Fetal heart while on oxytocin must be checked at least every ½ hour

INTERVENTION OF LABOUR

Considerable factors for intervention of labour

1. Cervical dilatation and descent

2. Presentation,

3. Fetal condition e.g. fetal distress

4. Maternal condition

5. Strength and frequency of uterine contractions

6. Moulding/caput formation score

INTERVENTION OF LABOUR cont

Consider all these factors, do not be guided only by the dilatation of the cervix in relation to the action line and by the descent of the fetal head, critical though these are.

Intervention needs to be earlier in a multip than in a prim. Some partograms have two action lines one at 3

hours for multips and one at 4 hours for prims

ABNORMAL PARTOGRAPM

Include the following

1. Prolonged latent phase

2. Protracted dilatation of cervix

3. Arrested dilatation of cervix

4. Protracted descent of the presenting part

5. Arrested descent of the presenting part

6. Prolonged second stage of labour

CAUSES OF ABNORMAL PARTOGRAPM

Divided into 3 Ps

1. Passenger relatedo Refers to the fetus: Big baby, hydrocephaly,

2. Power relatedo Refers to the expulsive efforts of the uterus and mother:

Poor uterine contractions etc

3. Passage relatedo Refers to the bony and soft tissue of the pelvis, vagina

and perineum: Contracted pelvis - CPD

SPECIAL CASES ON THE PARTOGRAM

Breech Twins IUFD Pre-eclampsia Previous scar Diabetes Cardiac diseases

NOTE: Plot the labour on the

partograph but specific WHO partogram may not apply

Such cases are managed individually

MANAGEMENT OF LABOUR IN SPECIAL CASES

1. BREECH Exclude reasons for immediate CS

previous CS, contracted pelvis Manage latent phase normally CS may be indicated if the 8 hour latent phase “action line”

is reached In the active phase, dilatation slower than 1cm/hr is a

worrying sign Consider oxytocin if dilatation moves to the right of the alert

line Reaching the action line is normally the indication for CS

MANAGEMENT OF LABOUR IN SPECIAL CASES cont

2. Multiple pregnancy Guidelines for breech apply i.e. prolonged

latent phase or reaching the action line is indication for CS

3. Pre-eclampsia Induction , augmentation and ARM may be

indicted early i.e. in the latent phase before 8 hours or before the action line

MANAGEMENT OF LABOUR IN SPECIAL CASES cont

4. IUFD Usually the WHO protocol can be

followed Only perform ARM in the active phase When intervention is indicated as per

WHO protocol– consider destructive delivery rather than CS

MANAGEMENT OF LABOUR IN SPECIAL CASES cont

5. Previous scar 2 previous CS or classical CS →

immediate CS Otherwise use WHO protocol but do not

use oxytocin Reaching the action line usually an

indication for CS

SUMMARY

Proper use of partogram is associated

with prevention of abnormalities of

labour as associated complications

and consequently reduction of both

maternal and perinatal mortalities and

morbidities