Partogram and Obstructed
Labour
H. Gee MD, FRCOG
Consultant Obstetrician
When is a Woman in
Labour?
Good Management of
Labour
First StagePatterns of
Aberrance
Patterns of Aberrance
• Prolonged Latent Phase
– Slow cervical dilatation before Active Phase established
– 20 hrs Nullips & 14 hrs Multips
• Primary Dysfunctional Labour
– Progress< 1 cm/hr before Active Phase slope established
– Incidence: Nullips 26%, Multips 8%
• Secondary Arrest
– Cessation after normal active phase dilatation
– Incidence: Nullips 6%, Multips 2%
PARTOGRAM- EAST AFRICA’S
GIFT TO THE WORLD
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Invented in Africa 1960’s
Identify delay
Identify increasing risk
To determine place of delivery
No comparative or controlled trials
Common sense value recognised
Cervical Dilatation (cms,)
Active Phase Cervicograms
- Philpott & Castle
10
8
6
4
2
0
2
4
6
8
10
Time (hrs.)
WHO Partograph Study
• Reduced incidence of prolonged
labour (8.3% vs 4.5%)
• Decreased need for augmentation
(32% vs 13%)
• Increased spont vag del (74% vs
78%)
• Decreased caesarean section
(9.8% vs 6.8%) *
* not Statistically Sig
Lancet 1994
343;1399-1404
(Nullips)
Why not done?
Result from Malawi audit
Partograph assessment by progress of labour and augmentation, by type of facility
Results from Malawi audit
Second Stage
• Descent
• Rotation
• Duration
– Passive
– Active(Pushing)
Current situation
• Midwife tells you CS needed
– Problems
• Is she right?
• Do you understand the problem & implications.
• Are there alternatives?
– e.g. forceps/vacuum in second stage
New situation
• You are team leader because of this
course
– When called
• You assess patient
– Power/passages /passenger
– You improve care by whole team
Parity & Obstruction
• Nulliparous
– Inertia
• Multiparous
– Uterine Rupture
COMPONENTS OF LABOUR
• The powers
Uterine contractions
• The passages
bony pelvis, and soft tissues
• The passenger
fetus
Powers
• Essential for good progress
– Cervical Dilatation
– Flexion
– Rotation
• Assessed by Palpation
– Frequency 3-5 in 10 min.
• Augmented by Oxytocin & Amniotomy
The Passages
• Bony pelvis
– Absolute cephalo-pelvic disproportion
• Kyphosis, Scoliosis, poliomyelitis, maternal
dwarfism, ricketts, pelvic fracture.
• Soft tissue
• fibroids, ovarian tumour, pelvic kidney, fat, cervical
stenosis, cervical cancer, vaginal\vulval atresia, vaginal
septum.
The Passages
Disproportion
• Head Not Engaged
– > 4/5 Palpable abdominally
– VE: high head, caput+++, moulding+++
• CS essential
• PPH
– Risk increased in Prolonged/Obstructed
labour
The Passenger-1
– Large Fetus
• Idiopathic
– Increasing Parity
• Pathologic macrosomia,
– diabetes
• Fetal abnormalities
– hydrocephalus
– conjoined twins
– hydrops fetalis
The Passenger-2
• Malposition
– Occipito-Posterior
– Mento-Posterior
• Malpresentation
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compound presentations
shoulder
brow
face
Signs of Obstruction
• Maternal
– Tachycardia
– Pyrexia
– Ketosis
– Dehydration
• Fetal
– Fetal heart rate abnormalities
Treatment
• General
– Re-hydration
– Anti-biotics (if infection suspected)
• Specific
– According to diagnosis
• Caesarean section
Caesarean Section in
Obstruction
• Cesarean Section Problems
– Impacted head – dis-impact before start
– PPH
• IV sytno/ergometrine/misoprostol ready
– Bladder Injury
• Leave catheter in for 10 days if blood stained
– Infection
• IV antibiotics
Post delivery
• Reflective practise- team leader
• Critical incident review
– WHY Poor Outcome?
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NO TRAINING
NO EQUIPTMENT
POOR COMMUNICATION
MATERNAL HEALTH VERY POOR
Improve Partogram Use
• 4 hourly ward rounds/teaching
• Critical incident review
– What was wrong?
• Audit
• Change
• Re-audit