Partograph & CTG PDF

# Partograph ## Outlines: - Introduction. - Definition of Partograph. - Objectives of Partograph. - Contraindications of Partograph. - Components of Partograph: 1. Fetal condition. 2. Labor progress. 3. Maternal condition. ## Definition: It is graphic recording of the progress of labor...

# Partograph ## Outlines: - Introduction. - Definition of Partograph. - Objectives of Partograph. - Contraindications of Partograph. - Components of Partograph: 1. Fetal condition. 2. Labor progress. 3. Maternal condition. ## Definition: It is graphic recording of the progress of labor, fetal condition and maternal condition against time in a single paper sheet. ## Objectives: - To detect abnormal progress of labor. - Serves as an "Early warning system". - To recognize cephalopelvic disproportion (CPD) before obstruction occurs. - Assists in early decision on transfer, augmentation, or termination of labor. - To recognize maternal or fetal problems as early as possible. ## Contraindications: 1. Woman has 9-10 cm dilatation on admission. 2. Elective CS. 3. Emergency CS immediately on admission. 4. Pregnant woman before 30 weeks of gestation. ## Components of the partograph: - Part I: Assessment of fetal condition. - Part II: Progress of labor. - Part III: Assessment of maternal condition. - Part IV: Outcome of labor. ## Part I - Assessment of Fetal Condition: ### 1- Fetal Heart Rate: The image shows a graph with a vertical axis labeled "Fetal heart rate" and a horizontal axis labeled "Hours". The vertical axis ranges from 100 to 180 bpm. The horizontal axis ranges from 0 to 24 hours. There are 12 vertical lines representing each hour. There are 12 horizontal lines representing each 10 bpm. #### # Listen: - Woman is in left lateral position. - Just after the contraction has passed its strongest phase. - For 1 full minute, every half hour, if FHR is abnormal measurement should be every 15mins. - If abnormal over 3 observations, take action. #### # Record: - At the top of the Partogram. - Every half hour. - The line of 120-160 is darker to remind the normal fetal heart rate. - Note: (FHR>160 is tachycardia, FHR<120 is bradycardia and indicate fetal distress, and when the FHR<100 indicate sever bradycardia). *** ## 2-Membranes and liquor: - It is recorded immediately below the fetal heart rate recording. - Intact membranes - I - Ruptured membranes + clear liquor - C - Ruptured membranes + meconium stained liquor - M - Ruptured membranes + blood stained liquor - B - Ruptured membranes + absent liquor - A ## 3-Moulding the fetal skull bones: It is an important indication for adequacy of pelvis for fetal head where the decrease in moulding with high head in the pelvis is a sign of cephalopelvic disproportion (CPD). It is recorded immediately beneath the state of membrane and liquor and plotted in the Partograph as follows: | Moulding | Description | |---|---| | 0 | No moulding | | + | Separated bones, sutures felt easily | | ++ | Bones just touching each other | | +++ | Overlapping bones | | ++++ | Severely overlapping bones | ## Part II Progress of labor: The image shows a graph with a vertical axis labeled "Cervix (cm) & Descent of head (plol)" and a horizontal axis labeled "Hours". The vertical axis ranges from 0 to 10 cm & 0 to 4 plol. The horizontal axis ranges from 0 to 24 hours. There are 24 vertical lines representing each hour. There are 10 horizontal lines representing each 1 cm on the cervix (cm) axis, and 4 horizontal lines representing each 1 plol on the Descent of head axis. There are two diagonal lines drawn on the graph, one labeled "Action" and the other labeled "Alert". This part of graph is used to monitor and assess progress of labor as follows: ### *Alert 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:* Action line has drawn 4 hours to the right of alert line and parallel to it. It is critical line specific management decision must be made. The progress of labor is monitored by: 1. **Cervical dilatation:** can be assessed through vaginal examination done at admission and once in 4 hour. - In latent phase (slow period of cervical dilatation is form 0-3 cm with gradual shortening of the cervix). The latent phase should normally not take longer than 8 hours. - In the active phase (faster period of cervical dilatation form 3-10 ). - In the center of Partograph is a graph. Along the left side are numbers 0-10 against squares (Each square represents 1cm dilatation). - Along the bottom of the graph is numbers 0-24 (Each square represents 1hour). - The dilatation of Cervix is plotted with an 'X'. - When labor goes from latent phase to active phase the dilatation recorded on alert line. - If woman admitted in active phase recording the cervical dilation starts on the alert line. - If the progress is satisfactory, the plotting of the cervical dilatation will remain on or to the left of the alert line. - Moving to the right of alert line indicates referral of mother to hospital. 2 **Descent of the head:** - It may not take place until the cervix has reached about 7 cm of dilatation. - This is measured by abdominal palpation and expressed in number of finger widths (fifths of the head) above the pelvic brim. - It is also recorded in the central part of the Partograph with an "O". - A head that is mobile above the brim will accommodate the full width of 5 fingers. - As the head descends, the portion of the head remaining above the brim will be represented by fewer fingers. - It is generally accepted that the head is engaged when the portion of the head above the brim is represented by 2 fingers (2/5) or less. - 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 contractions: - Observations are every one hour in latent phase. - Observations are every half hour in active phase. - Frequency: Number of contractions in a 10 minutes period. - Duration: Measured in seconds from the time the contraction sets in to the time the contraction passes off - Recording Uterine Contractions: On the Partograph below the time line, there are 5 blank squares going across the length of the graph (Each square represents 1 contraction). The duration is represented by different shading as follows: - If contraction last less than 20 seconds fill square with dots. - If between 20-40 seconds fill square by diagonal line - If contraction last more than 40 seconds fill the square completely by shading. ## Part III: Assessment of Maternal Condition It is recorded at the foot of the Partograph containing: 1. Pulse: every half hour. 2. BP: every 4 hrs or more frequently. 3. Temp: every 4 hrs or more frequently. 4. Urine: Protein, Acetone, Volume every 2 to 4 hour.. 5. Oxytocin regime. 6. Drug and I.V. fluid. ## Part IV: Outcome of labor Based on the observations of part one, two and three and after the delivery the baby the outcome is written. ## ANNEX 2: Partograph The image shows a table with rows corresponding to the following parameters: * **Date of admission:** * **Time of admission:** * **Fetal heart rate:** * **Liquor:** * **Moulding:** * **Cervix (cm):** * **Descent of head (plol):** * **Hours** * **Contractions per 10 mins** * **Oxytocin UL drops/min:** * **Drugs given and IV fluids:** * **Pulse and BP:** * **Temp °C:** * **Urine (protein, acetone, volume):** The table has 24 columns, each representing a single hour. ## Cardjotocography The image shows a fetus with an attached sensor. The sensor is connected to a monitor. ## Outlines: - Definition of Electronic Fetal Monitoring. - Indications of Electronic Fetal Monitoring:- - Maternal indications. - Fetal indications. - Methods of Fetal Heart Rate and Uterine Contraction:- - Indirect (External monitoring). - Direct (Internal monitoring). - Interpretation:- - Uterine Activity. - Fetal Heart Rate Parameters:- - Accelerations - Decelerations ## Definition of CTG: It is called electronic fetal monitoring that is a technical means of recording fetal heart rate (Cardio) and uterine contractions(toco), which performed during pregnancy, typically in the third trimester or continuously during labor. -CTG is include the external mode,which uses external transducer placed on maternal abdomen to assess FHR& UA, Internal mode which uses spiral electrode applied to fetal presenting part to assess FHR&UA. ## Indications: ### 1-Maternal conditions: - Medical Problems include:( hypertension - diabetes). - Augmentation of labor or induction. - Previous cesarean birth. - Prolonged rupture of membrane. - Antepartum haemorrhage. - Post-term pregnancy(>42 weeks gestation). - Premature labor. ### 2-Fetal conditions: - Fetal Growth Restriction. - Prematurity (<37 weeks gestation). - Abnormal fetal heart rate. - Oligohydramnios<500cc of amnion. - Congenital malformation. - Multiple pregnancies. - Breech presentation (Mal-presentation). ## Methods of fetal heart rate and uterine contraction monitoring:- 1. Indirect (external monitoring). 2. Direct (internal monitoring). ### 1. Indirect(External fetal monitoring):- Used to detect fetal heart rate and activity of uterine contractions by two separate transducers, one for the measurement of fetal heart rate and the Second one for assessing uterine contraction. ### 1- Ultrasound Transducer:- placed on the mother's abdomen( over the fetal back) that conducts the sounds of the fetal heart to a computer. The rate and pattern of the fetal heart are displayed on the computer screen and printed onto special graph paper. ### 2-Toco Transducer:- placed over the uterine funds to detect the tension of maternal abdominal wall as an indirect measure of the intrauterine pressure and converts the pressure into an electronic signal that is recorded on graph paper. #### Advantages:- 1. Easy to apply. 2. No complications for mother or fetus. 3. Non-invasive. #### Disadvantages:- 1. Difficult using with obese woman. 2. Restrict women movement. 3. Difficult in detecting intensity of contraction. 4. Affected with mother position. ### 2. Direct(Internal fetal monitoring):- The image shows a diagram of a fetus with two attached sensors. One sensor is labeled "Fetal scalp electrode (FSE), an internal fetal heart monitor" and the other is labeled “Intrauterine pressure catheter (IUPC), an internal contraction monitor". #### Technique: 1. Intrauterine pressure catheter (IUPC): is a device placed inside a woman's uterus to monitor uterine contractions during labor. The catheter measures the pressure within the amniotic space during contractions and can be used only after the membranes of the amniotic ruptured and cervix must be dilated 2-3cm can measure the frequency, duration and intensity of uterine contraction. 2. Fetal scalp electrode (FSE) (spiral electrode): small spiral electrode inserted via cervix attached to the presenting part shows a continuous fetal heart rate on the fetal monitor strip. #### Advantages: *It is the most accurate method for assessing FHR and uterine contractions. #### Disadvantages:- - Requires partial dilation of the cervix (at least 3cm). - Requires skilled particitioner to apply scalp electrode and IUPC. - Insertion of IUPC and FSE is uncomfortable for the mother. - Requires sterile equipment. - IUPC may be impossible to insert if the fetus at low station. - Thick fetal hair may make the attachment of fetal scalp electrode is difficult. ## Interpretation ### 1-Uterine activity:- -There are several factor used in assessing uterine activity: - **Frequency:** the amount of time between starting one contraction to the start of the next contraction - **Duration;** the amount of time from starting contraction to the end of the same contraction. - **Resting Tone:** a measure of how relaxed the uterus is between contractions. - **Interval:** the amount of time between the ends of one contraction to the beginning of the next contraction. ### Uterine activity may be: - Normal: less than or equal 5 contraction in 10 minute. - Abnormal: more than Scontraction in 10 minutes. The image shows a graph with a vertical axis labeled "Beginning of contraction / Acne / Relaxation" and a horizontal axis labeled "Duration of contraction / Frequency of contractions". The vertical axis represents the strength of the contraction, with the peak representing the "acmé" of the contraction. The horizontal axis represents the duration of the contraction and the frequency of the contractions. The graph illustrates the different stages of a contraction, including the beginning of the contraction, the increment, the acmé, the decrement, and the relaxation. ## Fetal heart rate parameters The normal :is between 120-160bpm ### Abnormal pattern include: 1. **Fetal bradycardia;** the fetal heart rate <120 bpm for 10minutes a moderate bradycardia 100-119bp/min not serious and may result from the compression head during labor marked bradycardia less than 100bpm/min is sign of hypoxia. The image shows a graph with a vertical axis labeled "BPM" and a horizontal axis labeled "Time". The vertical axis range from 60 to 80 bpm. The graph illustrates a fetal heart rate pattern that is considered bradycardia, with the fetal heart rate dipping below 80 bpm for a sustained period of time. 2. **Fetal tachycardia;** the fetal heart rate>160bpm for 10 minutes a moderat tachycardia of 160:180 is not serious, marked tachycardia (>180bpm) may be caused by fetal hypoxia- maternal fever -maternal anemia. The image shows a graph with a vertical axis labeled "BPM" and a horizontal axis labeled "Time". The vertical axis range from 160 to 180 bpm. The graph illustrates a fetal heart rate pattern that is considered tachycardia, with the fetal heart rate exceeding 180 bpm for a sustained period of time. ## Acceleration It is a transient increase in FHR of 15 bpm or more and lasting for 15 sec. The image shows a graph with a vertical axis labeled "Fetal heart rate (BPM)" and a horizontal axis labeled "Time (sec)". The vertical axis range from 30 to 240 bpm. The horizontal axis range from 0 to 100 sec. The graph illustrates a fetal heart rate pattern that is considered acceleration, with the fetal heart rate increasing by 15 bpm or more and lasting for 15 seconds. ## Deceleration Decrease in FHR of 15 p/min from the baseline for 15sec. The image shows two graphs, each illustrating a different type of deceleration: 1. **Early Deceleration:** The graph shows a dip in the fetal heart rate that coincides with the peak of the uterine contraction. This deceleration is considered benign and typically reflects a head compression. 2. **Late Deceleration:** The graph shows a dip in the fetal heart rate that occurs after the peak of the uterine contraction. This deceleration is considered more serious and may indicate a problem with oxygenation to the baby. ## D-Cesarean birth: ### Cesarean Section The image shows four diagrams illustrating the steps involved in a Cesarean Section: 1. **A cut is made in the abdomen and then another one in the uterus.** 2. **The baby is removed.** 3. **The placenta is removed.** 4. **The cuts in the uterus and skin are then closed with stitches.** ## Definition: It is a surgical procedure involving incision of the walls of the abdomen and uterus for delivery of the baby. ## Indications: ### Maternal **Absolute:** - More than 2 previous cesarean sections - Obstructive lesions in the lower genital tract including malignancies. - Bad obstetric history. **Relative:** - Previous uterine surgery: myomectomy or hysterotomy. - Dystocia - Pre-eclampsia or heart disease. - Inflammatory bowel disease. - Maternal infection: primary genital herpes, HIV. ### Fetal - Abnormal presentations. - Multiple pregnancies. - Fetal distress. - Large size of the fetus compares to birth canal. ### Maternal-fetal - Placenta previa - Obstructed labor ## Types: ### According to time : 1. **Elective:** operation done before onset of labor. 2. **Selective:** operation done after onset of labor. 3. **Emergency:** it done at emergency situation as uterine rupture. ### According to site: 1. **LSCS:** lower segment cesarean section. 2. **USCS:** upper segment cesarean section. ## Complications: ### Risks to baby: - **Breathing problems.** Babies born by scheduled C-section are more likely to develop transient tachypnea condition that makes it difficult for the baby to breathe. - **Surgical injury.** Although rare, accidental nicks to the baby's skin can occur during surgery. ### Mother complications: **1. Operative:** - Anesthetic complications: aspiration of gastric content. - Primary hemorrhage → shock - Injury: for urinary bladder or ureter. - Fetal injury during opening of the uterus. **2. Postoperative:** - Pulmonary complications: pulmonary embolism, pneumonia & bronchitis. - Intestine: paralytic ileus, adhesion, & intestinal obstruction. - Urinary tract: infection, retention of urine & fistula. - Genital: endometritis. - Wound: infection, rupture scare in subsequent pregnancy. - Thrombophlebitis. - Puerperal sepsis. ## Nursing intervention: ### Preoperative care: - Explain the procedure to the mother. - Fasting: the women should be fasting for at least 5hrs prior to surgery. - Bowel preparation: it is important that the woman is not grossly constipated at the time of surgery. - Bladder preparation: the woman should be encouraged to empty bladder before operation. - Pubic shave: this may be necessary as the incision is going to be along the supra pubic hair line. - Premedications: this may include prophylactic antibiotic therapy. - Bath and shower: this should be taken prior to surgery. It well enables the woman to feel clean and refreshed. - Any jewelry should also be removed. ### In the operating room: - Prepare the necessary equipment and place them in order. - Apply the woman in appropriate position. - Insert canola - Insert the urinary catheter - Clean the operation site with antiseptic solution. ### After operation: - **Positioning the woman:** - Woman who has had spinal anesthesia is placed flat. - Woman who have had general anesthesia is placed on one side with the head slightly elevated. - Change position every 2 hours to improve ventilation and reduce pooling of lung secretions. - **Measure vital signs** every 15 min for 1 hour, then every 30min for the second hour then every 4 hour for the rest of the 24 hour. - **Anesthesia- related interventions:** - Monitor the return of sensation to the legs if a regional anesthesia was used. - Assess the woman's level of consciousness if general anesthesia was given. - Check level of the uterine Fundus. - To ensure that the uterus had nearly return to it position. - **Assessing the breast:** - Inspect the breasts for size, contour, asymmetry, engorgement or areas of erythema. - Palpate the breasts to ascertain if they are soft, filling, or engorged and for tenderness - Check the nipples for cracks, redness, fissures, or bleeding and note whether they are erect, flat or inverted. - Record the findings. - **Providing breast care** as follows: 1. Before feeding the baby, instruct the mother to wash her hands and then wipe off her nipple with plain water. 2. After feeding, instruct the mother to wipe off her nipple with plain water and to expose it to air to allow it to dry. 3. Ask the woman to wear well-fitting supportive bra. - **Observe lochia** (amount, odor, consistency). The amount of lochia can be calculated as follows: - Scant amount: blood only on tissue when wiped or less than one inch stain on peripad within 1 hour - Light amount: less than 4- inch stain on peripad within 1 hour - Moderate amount: less than 6- inch stain on peripad within 1 hour - Heavy amount: saturated peripad within 1 hour. - **Observing the surgical dressing** for intactness and discharge: Circle and write date/time on drainage area with a pen, the circle allows other nurses to see how much bleeding has occurred at a given time. - **Assessing intake and output.** - **Assessing the gastrointestinal function:** - Auscultation for bowel sounds until normal peristalsis is noted in all abdominal quadrants. - Ask the woman if she pass flatus or stool. - **Assessing the lower extremities:** - Checks the legs for localized areas of redness, heat, edema and tenderness. - Assessing for Homan's sign as follows: - Position the woman's legs flat in the bed. - Then place one hand under the leg near the back of the knee. - With the other hand gently flex her foot forward toward her ankle and asks if she feels any calf pain (no pain is a negative Homan's sign; pain is a positive Homan's sign). - Report positive Homan's sign to the doctor immediately. - **Check pain status:** - Asking the woman about type, location, and severity of pain. - Administer medications as ordered. - **Assessing emotional status:** - Be alert for mood swings, irritability, or any crying episodes. - **Encourage early ambulation** to avoid thrombosis. - **Encourage woman to cough and deep breathing exercises.** ## References: 1. Ricci S., Kyle T., and Carman S. Maternal and Pediatric Nursing. 3rd ed. China, Lippincot Williams and Wilkins Com.,2017. 2. Murrey Sh., and Mickinney E. Foundations of Maternal – Newborn Nursing and Woman's Health Nursing. 7th ed., United State of America, Elsevier, 2019. 3. Pillirtteri A. Maternal and Child Health Nursing: Care of Childbearing And Childrearing Family. 7th ed., New York, Lippincot Williams and Wilkins Com.,2018. 4. Chandroo M. Instruments in Obstetric and Gynecological Nursing, 1st ed., India, CBS com., 2013; 90-216. 5. Types of episiotomy available at https://www.healthline.com/health/pregnancy/episiotomy-types, retrieved from 20 October 2020 at 5:57 pm. 6. Complication of forceps delivery available at, https://www.mayoclinic.org/tests-procedures/forceps-delivery/about/pac-20394207 retrieved from 20 October 2020 at 9:05 pm. 7. Indications of forceps delivery available at, https://www.ncbi.nlm.nih.gov/books/NBK538220/ retrieved from 20 October 2020 at10:13pm. 8. Indications and complications of vacuum extractor available at https://www.mayoclinic.org/tests-procedures/vacuum-extraction/about/pac-20395232 retrieved 20 October2020 at 11:08pm