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