Principles of Intrapartum Monitoring and Labor Care Guide PDF

Principles of Intrapartum monitoring with the Partograph and Labour Care Guide Prof Jamilu Tukur Federal Teaching Hospital/ Umaru Musa Yaradua University, Katsina Outline of presentation Introduction to the Partograph: History, importance, Role i...

Principles of Intrapartum monitoring with the Partograph and Labour Care Guide Prof Jamilu Tukur Federal Teaching Hospital/ Umaru Musa Yaradua University, Katsina Outline of presentation Introduction to the Partograph: History, importance, Role in intrapartum monitoring Practical tips on the utilization of the Partograph Case studies Introduction to the LCG Practical tips on the utilization of the LCG Case studies Conclusion Introduction to the partograph Definition: A graphical representation of events in labour measured against time in hours In, 1954 Friedman prepared the cervicography. In 1972 Philpott and Castle, working in Rhodesia (now Zimbabwe), developed the first partograph, by utilizing Friedman's cervicograph, and adding the relationship of the presenting part to the maternal pelvis Philpott and Castle in 1973 introduced the concept of "ALERT" and "ACTION" lines. in 1987, the World Health Organization produced a partograph with a view to improving labour management and reducing maternal and fetal morbidity and mortality Importance and role of partograph Prevents : Prolonged labour CPD: Dehydration, sepsis, obstructed labour, fistaulae, ruptuerd uterus Inefficient uterine action PPH Maternal mortality Perinatal mortality Perinatal sepsis Partograph use is for health workers that can: Conduct and observe normal labour Perform vaginal examinations and assess cervical dilatation Plot cervical dilatation against time Not for: Home delivery Untrained health workers Composite WHO Partograph Has 8 hours of latent phase of labour Alert line represents minimum progress at 1cm/ hr Action line is 4 hours parallel to the alert line In between is the transfer zone Modified WHO Partograph Latent phase removed To be filled from active phase (Cervical dilatation of 4 cm) Alert and action line controversies at tertiary health facilities Main Components of the partograph Fetal condition Progress of the labour Maternal condition NOTE: A small box covers a period of 30 mins while the bigger box covers 1 hour Pelvic examination 4 hourly while some centers do 3 hourly Period could be shorter when 2nd stage is anticipated or due to fetomaternal condition Partograph to be filled for all parturients in active phase of labour There is room for writing text Patient information Patients name, age, parity, hospital number, date and time of admission Duration of ruptured membrane I Fetal condition The fetal heart rate is counted and recorded every 30 mins in the 1st stage and every 15 minutes in the second stage of labour Normal is 110-160/ minute Membranes and moulding Membranes and liquor: Record at every vaginal examination 4 hourly as follows: I: intact membranes C: clear liquor M: meconium–stained liquor B: blood–stained liquor Moulding: Record at every vaginal examination 4 hourly as follows: Sutures apart (-) sutures apposed (+) sutures overlapped and reducible (++) sutures overlapped and not reducible (+++) Cervical dilatation Assess cervical dilatation at every vaginal examination and plot with X. Place on the pre-drawn Alert line at the cervical dilation that corresponds to the cervical dilatation found during pelvic examination. The vertical line corresponding to this point is the Zero hour along which all the first entries will be made in the partograph.  Where a partograph does not have pre-drawn alert and action lines, the cervical dilation should be first entered, then the Alert line should be drawn from that point at 1cm/hour to 10cm cervical dilation. The action line will then be drawn 4 hours to the right and parallel to the alert line. Descent of the presenting part marked with O in a cephalic presentation and W in a breech presentation Uterine contractions Chart uterine contractions every 30 minutes; palpate and count the number of contractions in a 10- minute time period, and their duration in seconds. Less than 20 seconds (weak): Dots Between 20 and 40 seconds (moderate): Lines More than 40 seconds (strong): shading Medications and maternal vital signs Record the amount of oxytocin per volume IV fluids given if used; Record any additional drugs given; Record maternal pulse every 30 minutes and mark with a dot (.); Record blood pressure every four hours and mark with arrow (↕); Record temperature every two hours; Measure urinary volume, protein and acetone and record each time the woman passes urine. Summary of labour Summary of induction/ onset of labour Method of delivery Placenta and membrane Perineum: Intact/ laceration/ episiotomy Blood loss Details of the baby Mothers condition one hr postpartum Case study 1 Mrs AA. Gravida 2 para 1+0, Hosp no 134, at a gestational age of 39 weeks admitted on the 1st of January 2025 by 8am. 3 contractions in 10 mins lasting 40s. Descent 3/5. Fetal heart rate was 140/ min. Pelvic exam: Cervix 7 cm dilated. Membranes absent. No caput or moulding Clear liquor. Pr 80/min BP: 120/80mmHg. Temp 36.8c 11am: 4 contractions in 10 mins lasting 50s. Descent 2 /5. FHR 156/min. Fully dilated. Clear liquor. PR 90/min. BP 130/90mmHg Temp: 37.2c Case study 2 Mrs BB. Gravida 3 para 2+0, Hosp no 2355, at a gestational age of 38W5D weeks admitted on the 1st of January 2025 by 8am. 3 contractions in 10 mins lasting 40s. Descent 3/5. Fetal heart rate was 150/ min. Pelvic exam: Cervix 5 cm dilated. Membranes absent. No caput or moulding Clear liquor. Pr 80/min BP: 130/80mmHg. Temp 37.4c 12 noon: contractions 2 in 10 mins lasting 20s. Descent 2 /5. Cx 6 cm dilated. Clear liquor. PR 90/min. BP 130/90mmHg. FHR 160/minute Temp: 37.2c What is the diagnosis? How will you treat the patient? LABOUR CARE GUIDE A monitoring tool developed by the WHO aimed at providing good quality, evidence based and respectful care during the intrapartum period Has been adopted for use in Nigeria by the FMOH AIM OF THE LCG Guide the monitoring and documentation of the well-being of women and babies and the progress of labour Guide skilled health personnel to offer supportive care throughout labour to ensure a positive childbirth experience for women assist skilled health personnel to promptly identify and address emerging labour complications, by providing reference thresholds for labour observations that are intended to trigger reflection and specific action(s) if an abnormal observation is identified Prevent unnecessary use of interventions in labour Support audit and quality improvement of labour management  The LCG has been designed for the care of women and their babies during labour and childbirth. It includes assessments and observations that are essential for the care of all pregnant women, regardless of their risk status Documentation on the LCG of the well-being of the woman and her baby as well as progression of labour should be initiated when the woman enters active phase of the first stage of labour (5 cm or more cervical dilatation), regardless of her parity and membranes status.  For whom should the LCG be used?: All women in labour. High-risk women may require additional monitoring and care. When should the LCG be initiated?: When women have entered the active phase of the first stage of labour (i.e. cervical dilatation of 5 cm or more). Where should the LCG be used?: The LCG is designed for use at all levels of care in health facilities. Sections of the LCG 1. Identifying information and labour characteristics at admission 2. Supportive care 3. Care of the baby 4. Care of the woman 5. Labour progress 6. Medication 7. Shared decision-making Sections 1, 2, 3, 4; Identifying info, supportive care, care of the baby, care of the woman Section 5 and 6: Labour progress and medication Section 7: Shared care  For all observations entered into the NLCG, there is a: Time axis: a horizontal time axis for documentation of the corresponding time of observation Reference axis: a vertical reference values axis for determination of any deviation from normal observations. The decision to intervene in the course of labour is primarily based on observation of a deviation from expected observations during these assessments LCG provides explicit reference values for labour observations A section to document shared decisions to address any deviation from the expected norm ARCP approach Assess → Record →Check → Plan approach, which involves: Assess (assess the well-being of woman and her baby, and progress of labour) Record (document labour observations) Check reference threshold (compare labour observations with reference values in the “Alert” column) Plan (decide if and what interventions are required, in consultation with the woman, and document accordingly). The reference (“Alert”) column The “Alert” column presents thresholds for abnormal labour observations that require further assessment and action by the health-care provider. If labour observations do not meet any of the criteria in the “Alert” column, labour progression and care should be regarded as normal, and no medical intervention is warranted. Observations/ entries Observation/entry Abbreviation Section 1: Identifying The frequency of observations information and labour characteristics at admission is like that in the previous Rupture of membranes (Date; U = unknown partograph design Time) Nomenclature to complete Section 2: Supportive care the LCG: Where a Companionship Y = Yes measurement is numerical, N = No use number. When documenting non- D = Woman declined numerical observations, a list Pain relief Y = Yes of abbreviations is used to N = No allow consistent interpretation D = Woman declines of the “Alert” column examples as shown Oral fluid Y = Yes N = No D = Woman declines How to complete Section 1: Identifying information and labour characteristics at admission Important demographic and labour characteristics, such as the woman’s age, gestational age, serology results, haemoglobin, blood type and Rh factor, referral status and cause, and symphysis–fundal height How to Complete Section 2: Supportive care Step 1: Assess Step 2: Step 3: Step 4: Plan Record Check threshold This includes labour Companio n Does the woman Y = Yes have a companion N = No Alert: N = No If recorded you companionship, access to of her choice D = Woman “No”, offer to pharmacological and non- present providing support and Declines find companion of a pharmacological pain at the time of the woman’s relief, ensuring women assessment? choice. If you are offered oral fluid, and recorded techniques to improve “Yes” or women’s comfort “Declines”, continue to This should be recorded assess preference her hourly during the progress of labour and childbirth. Filled Section 2 Section 3: Care of the baby Step 1: Step 2: Step 3: Step 4: Assess Record Check Plan Regular observation of Fetal heart Listen to the Record the Alert: 160. 160: Ask FHR and of amniotic beats minute per 1 minute. the to woman turn on fluids, fetal position, her left side, moulding of the fetal then alert a senior care head, and development of provider and caput succedaneum follow clinical guidelines Completed section 3 Section 4: Care of the woman The woman’s health and Step 1: Step 2: Step 3: Step 4: Plan Assess Check well-being are monitored threshold on the LCG by regular observation of the pulse, blood pressure, Pulse Count Record Alert: 120 senior care provider and follow pulse rate s pulse local guidelines. for at least (bpm) If pulse >60 or 6 h when lag Section 5: Labour progress after obtaining labour, the woman’s “X” in plot the (cervical dilatation time current for consent and cell that remains at cervical ensuring matches the 5 cm for 6 dilatation privacy. time and the or more or in cervical hours) second dilatation  6 cm = >5 h stage is Regular observation of the In the (cervical exceeded frequency and duration of second dilatation with no contractions, cervical stage, insert remains at progress. “P” to 6 cm for 5 During the dilatation and descent of indicate or more first stage, the baby’s head when pushing  hours) if 7 cm = >3 h progresses labour begins (cervical as dilatation expected, remains at assess 7 cm for 3 cervical or more dilatation hours) every 4 hours unless Completed section 5 Section 6: Medications This section aims to Step 1: Step 2: Record facilitate consistent Oxytocin Is oxytocin currently  being administered If not oxytocin is being recording of all types of to the woman? administered, medication used during  record N= No If oxytocin is labour, by describing being whether the woman is administered, receiving oxytocin, and its record the amount of dose, and whether other oxytocin in medications or IV fluids units per (U/L) and drops litre are being administered per minute (drops/min)  When oxytocin is used, record the amount  Record Section 7 Assessm Record the overall assessment and any additional findings not ent previously documented but important for labour monitoring. Plan Record the plan following assessment for example: ▪ Continuation of routine monitoring This section aims to ▪ Prescription of diagnostic tests ▪ Augmentation of labour with oxytocin infusion facilitate continuous ▪ Assisted birth with vacuum or forceps communication with the ▪ Caesarean section woman and her Take into consideration that women should be involved in discussions and be allowed to make informed decision. companion, and the consistent recording of all assessments and plans agreed. Completed section 6 and 7 Second stage Findings recorded on the right side of the chart including birth  How to Complete Section 8: ThisDelivery section aims Outcome Model of Was the mode of Circle “spontaneous” if the labour starts and ends to facilitate Delivery delivery without requiring use of tools or any intervention to monitoring and spontaneous, deliver the baby. assisted breech, Circle “assisted breech delivery” if there is recording of all vacuum spontaneous delivery of the buttocks up to the level of assessments in extraction, umbilicus followed by assisting with the delivery of the the fourth stage of forceps, remaining part of the body. destructive, C/S Circle “vacuum extraction/forceps” when the delivery of labour and the or others. the baby is aided with instruments. immediate post- Circle “destructive” procedure if there was an aim at reducing the size of the baby to allow delivery. partum period. Circle “C/S” if there was an operation aimed at delivering the baby through the abdomen. Circle “others and Specify” if other methods of delivery are used. Case study Conclusion LCG is evidence based and adaptable in all clinical care settings However, needs training for effective implementation Reference WHO labour care guide: user’s manual. Geneva: World Health Organization; 2020. Licence: CC BY-NC- SA 3.0 IGO  Thanks for listening