Partogram Or Partograph

INTRODUCTION:

Partograph is a Greek word which means “Labour Curve”. Partograph or Partogram is a simple, Inexpensive tool which gives continuous pictorial overview of labour. It is the easy way to detect prolonged labour. The common obstetric Emergencies are obstructed labour and prolonged labour. Obstructed labour means no progress in descending parts inspite of good uterine contractions and the appropriate management would be the Caesarean section. In Prolonged labour the Cervix dilates slowly and incompletely and vaginal delivery may be considered under medical supervision. Obstructed and Prolonged labour complications are rupture of uterus, fetal distress and fetal Death. Slow progress in labour results in postpartum hemorrhage (PPH), Infections and Obstetric fistulae. To prevent life threatening situations in labour it is important that the signs of Obstructed & Prolonged labour identified early in Peripherals where the emergency management facilities are not available.

BACKGROUND:

Friedman is the first Obstetrician to provide a tool for the assessment of individual labour (Cervicograph).In 1972, Philpott developed Partogram from Cervicograph in Zimbabwe and Later Philpott and Castle introduced an ‘Action Line’ & ‘Alert Line’ in the Partogram. John Studd promoted the use of Partograph in United Kingdom.

THE CONCEPT OF PARTOGRAPH:

It is a record of all observations made on a woman in labour
Decision making tool
Implies a functioning referral system with essential Obstetric service
It improves Efficiency and Effectiveness of Maternity Services

DEFINITION:

A Partograph is a tool to help in the management of labour for the identification of women who are not likely to have a normal delivery and who need medical assistance. Partograph is a chart in which the salient features of labour are entered in a graphic form and it provides the opportunity for early identification of deviations from normal. A Partograph is a graphical record of progress during labour. Progress measured by cervical dilatation against time in hours & it provides a record of the important conditions of the mother & fetus that may arise during the process of labour.

OVERVIEW:

The Partograph can be used by midwives and health workers with adequate training in midwifery who are able to:
Observe and conduct normal labour and delivery.
Perform vaginal examination during labour and assess cervical dilation accurately.
Plot cervical dilation accurately on a graph against time.

PURPOSE OF THE PARTOGRAPH:

1) To detect abnormal progress of labour as early as possible
2) To prevent prolonged labour
3) To recognize CPD long before obstructed labour
4) To assist in early decision on transfer, augmentation or termination of labour
5) To increase the quality and regularity of all observations of mother and fetus
6) To recognize maternal or fetal problems as early as possible

OBJECTIVE OF INTRODUCTION OF PARTOGRAPH:

Partograph facilitates the providers in
a) Differentiating between latent and active phase of labour and its deviation from normal b) Monitoring the progress of labour and well being of mother and fetus c) Recognizing the need for action at the appropriate time

FUNCTIONS OF PARTOGRAPH:

Give early warning in prolonged labour.
Moving to the right of the alert line serves as a WARNING for extra vigilance and specific management decisions must be made.
Other observations on the progress of labour also recorded.

COMPONENTS OF THE PARTOGRAPH:

Part I Assessment of fetal condition
Part II Progress of labour
Part III Assessment of maternal condition
Part IV Outcome of labour

PART I – ASSESSMENT OF FETAL CONDITION

This part of graph is used to monitor and assess fetal condition A) Fetal Condition includes -Fetal Heart Rate (FHR) and Membranes and liquor. B) Moulding of the fetal skull bones.

A) Fetal Condition

i) Fetal Heart Rate

* 120 – 160 b.p.m. Is normal and > 160 b.p.m. Tachycardia.
* < 110 b.p.m. Bradycardia and < 100 b.p.m. severe Bradycardia

ii) Membranes and liquor
The condition of membranes and liquor plotted in the partograph as follows Intact Membranes I
Ruptured Membranes + Clear liquor C
Ruptured Membranes + Blood-stained liquor B
Ruptured Membranes + Absent liquor A
Ruptured Membranes + Light green liquor M+
Ruptured Membranes + Dark green liquor M++
Ruptured Membranes + Meconium stained liquor M+++

B) Moulding the fetal skull bones:

It is important indication for adequacy of pelvis for fetal head. Decrease in Moulding with high head in the pelvis is a sign of Cephalo Pelvic Disproportion (CPD).It is plotted as follows:

Separated bones, sutures felt easily O
Bones just touching each other +
Overlapping bones (reducible) ++
Severely overlapping bones (non-reducible) +++

Part II Progress of labour:

This section has as its central feature a graph of cervical dilation against time.

Alert Line (Health facility line)
The alert line drawn from 4cm of cervical dilatation to the point of expected full dilatation at the rate of 1cm / hr. Moving to the right of alert line indicates referral of Mother to hospital.

Action Line (Hospital line)

Action line has drawn 4 hours to the right of alert line and parallel to it. It is critical line specific management division must be made. The progress of labour is monitored by
1. Cervical dilation
2. Descent of the head – abdominal palpation of the head
3. Uterine contractions – frequency/10mts and duration

1. Cervical Dilation: It gives most important information and also it is the surest way of assessing progress of labour. When progress is normal and satisfactory plotting cervical dilation remains on the Alert line or left of it. If woman admitted in active phase recording the cervical dilation starts on the alert line. 2. Descent of the Head: It is assessed by abdominal Examination by using rule of fifths to assess engagement. Rule of fifths means the palpable fifths of the fetal head are felt above the level of Symphysis pubis by abdominal examination.2/5 or less than that of the fetal head felt above the level of Symphysis pubis indicates head is engaged. By per vaginal examination findings can be confirmed that the lowest part of vertex has passed or is at the level of ischial spines.

3. Uterine contraction: In normal labour uterine contractions become more frequent and last longer as labour progresses. The observations of duration of contractions assessed by number of contraction in 10mts period, the time the contraction felt abdominally, to the time the contraction passes off. In Partogram each square represents one contraction. If contraction last for 20 seconds or less fill square with dots. If between 20-40 seconds by diagonal line and >40 seconds fill the square completely by shading.

Part III Assessment of Maternal Condition

Assess maternal condition regularly by monitoring. Drugs, IV fluids, Pulse – Half hourly, BP-4th hourly, Temperature – 4th hourly and Urine volume, analysis for protein and acetones every 2 to 4 hourly.

Part IV Outcome of labour

Based on the observations of part one, two and three and after the delivery the baby the outcome is written.

Points to remember while using Partograph

➢ It is only a tool for managing labour progress
➢ Only start partograph who don’t have complications and doesn’t require Referral ➢ Only be started when a woman is in labour
➢ If progress of labour is satisfactory, the plotting cervical dilation remain on/to the left of the Alert line ➢ If labour is satisfactory, the dilation should move to right of the Alert line ➢ Cervical dilation plotted as ‘X’, descent of fetal head plotted as ‘O’, uterine contractions are plotted with differential shading ➢ Descent of fetal head always assessed by Rule of fifths felt above the pelvic brim, immediately before doing vaginal examination ➢ Assessing descent of the head helps in detecting progress of labour ➢ Moulding with high head indicates CPD and requires immediate referral ➢ Infrequent vaginal examination (once in every 4hrs)

➢ When the woman arrives to the hospital the time of admission is O time ➢ A woman whose cervical dilation moves to the right of the Alert line must be transferred for obstetric interventions

When Partogram should be initiated

– When CD is 3cm or more
– Uterine contractions one or more in 10mts and last for at least 20 seconds

Condition need to be screened prior to Partogram

Short stature, APH, Severe Pre-eclampsia, Fetal compromise, Previous caesarean section, Moderate to severe anemia, Multiple pregnancies, Mal-presentations, Very pre-mature labour and Obvious obstructed labour

Pre-requisites for its use

Good understanding is essential to start Partograph
-Understands normal and abnormal partograph
-Necessary needed skills are accurate recording, Interpretation, and Timely
communication. – Referral and intervention

Quick action warranted in labour during following conditions

– Delay in cervical dilatation is 1cm/hr
– Delay in descent of the head
– FHR < 120 or > 160/mt on 3 observation
– ROM and Meconium stained liquor
– ROM and Absence of liquor and fetal skull Moulding with bones touching each other / overlapping / severe overlapping

REFERENCES

1. Integrated Management of Pregnancy and Child birth – Managing Complications in Pregnancy and Child birth: A Guide for Midwives and Doctors., WHO 2003. 2. Ministry of Health., Integrated Reproductive Health Curriculum – Safe motherhood Module., May 2001. 3. Safe Motherhood – Preventing Prolonged Labour: a practical guide., WHO 1994. 4. Community Health & Disease Surveillance News letter., “Optimal use of Partograph in obstetric practice., 13(12)., 6-7. 5. Tina Lavender., “NCT Evidence based briefing- Use of the Partogram in Labour”., 14-16.