Welcome to the 11th PLGPMI National General Assembly

1. Welcome to the 11th PLGPMI National General Assembly MIDWIVES Embracing Development, Coping with Change Manila Hotel

2. GOOD MORNING PARTOGRAPH Made Easy LOURDES BORJA MAGBANUA, RM, RN, RT, MAN, Ph.D

3. Partograph Made Easy 

4. I. The Partograph A tool to help in management of labor Guides birth attendant to identify women whose labor is delayed and therefore decide appropriate action The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor. The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor.

5. This is the original version of the WHO partograph.This is the original version of the WHO partograph.

6. This is the newest version of the partograph and the one that we will be using during this training.This is the newest version of the partograph and the one that we will be using during this training.

7. OBJECTIVES To understand the concept of the WHO partograph To explain to mothers the significance of the graph To record the observations accurately on the graph To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral

8. Monitor during labor� Progress of labor Cervical dilatation Contraction pattern Maternal well being Pulse, temperature, blood pressure Urine voided Fetal well being Fetal heart rate and pattern Color of amniotic fluid

9. The parts of the partograph The upper colored portion is where you plot the progress of labor. The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.The upper colored portion is where you plot the progress of labor. The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.

10. Let us enlarge the upper portion of the partograph. As you can see it is divided evenly into small boxes by gridlines vertically and horizontally. Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to 10. While the vertical gridlines indicate the time, in hours, the patient is in active labor. The upper portion is also divided into 3 colors � green, yellow, and red. The boundary between the green and yellow parts forms a diagonal line which is highlighted here. This is designated as the alert line which starts at 4 cm. up to 10 cm. Let us enlarge the upper portion of the partograph. As you can see it is divided evenly into small boxes by gridlines vertically and horizontally. Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to 10. While the vertical gridlines indicate the time, in hours, the patient is in active labor. The upper portion is also divided into 3 colors � green, yellow, and red. The boundary between the green and yellow parts forms a diagonal line which is highlighted here. This is designated as the alert line which starts at 4 cm. up to 10 cm.

11. Parallel and 4 hours to the right of the alert line is another line formed by the boundary between the yellow and red part which is again highlighted here. This is the action line. Note that it too starts at 4 cm and ends in 10 cm.Parallel and 4 hours to the right of the alert line is another line formed by the boundary between the yellow and red part which is again highlighted here. This is the action line. Note that it too starts at 4 cm and ends in 10 cm.

12. Conditions that does not need the use of partograph Antepartum hemorrhage Severe pre-eclampsia and eclampsia Fetal distress Previous cesarean section Multiple pregnancy Malpresentation Very premature baby Obvious obstructed labor The partograph need not be used in all pregnant or laboring patients especially those who are for cesarean delivery like those with malpresenting babies (breech or transverse lie), those with scarred uteri, those with antepartum hemorrhage (like placenta previa). It is also not needed in those who have to be delivered immediately because of fetal distress or those with severe uncontrolled pre-eclampsia and eclampsia. Likewise it may not be appropriate for those with twins or very premature baby.The partograph need not be used in all pregnant or laboring patients especially those who are for cesarean delivery like those with malpresenting babies (breech or transverse lie), those with scarred uteri, those with antepartum hemorrhage (like placenta previa). It is also not needed in those who have to be delivered immediately because of fetal distress or those with severe uncontrolled pre-eclampsia and eclampsia. Likewise it may not be appropriate for those with twins or very premature baby.

13. II. Recording the findings in the partograph Start by labeling the record with pertinent patient identifying information.

14. Plotting the progress of labor Plot only the CERVICAL DILATATION using the symbol �X� Start when woman is in ACTIVE LABOR (4 cm or more) and is contracting adequately (3-4 contractions in 10 minutes)

16. You do not always have to start the plotting in the 4 cm line since not all patients are first seen at this cervical dilatation. If the patient arrives at 6 cm cervical dilatation start plotting in the 6 cm line but still in the alert line.You do not always have to start the plotting in the 4 cm line since not all patients are first seen at this cervical dilatation. If the patient arrives at 6 cm cervical dilatation start plotting in the 6 cm line but still in the alert line.

17. If she is first seen at 8 cm, then start at the 8 cm line but still on the alert line.If she is first seen at 8 cm, then start at the 8 cm line but still on the alert line.

21. Encourage audience participation.Encourage audience participation.

24. III. Distinguishing normal from abnormal labor pattern

28. If plotting passes alert line � Reassess woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminent Alert transport services Monitor intensively

29. What to do if partograph passes alert line  Reassess woman and consider criteria for referral. Alert transport services. Empty bladder. Ensure adequate hydration but omit solid foods. Encourage upright position and walking if woman wishes. Monitor intensively. If referral long, reassess in 2 hours and refer if no progress. If partograph passes action line, refer urgently to an EmOC facility unless imminent delivery.

30. If plotting reaches the action line�the patient must be already in an EmOC facility, a decision made about the cause of slow progress, and appropriate action taken EmOC facility is a hospital with capability for Emergency Obstetric Care.EmOC facility is a hospital with capability for Emergency Obstetric Care.

31. The parts of the partograph The upper colored portion is where you plot the progress of labor. The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.The upper colored portion is where you plot the progress of labor. The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.

32. As I have said below the colored part is where you are supposed to write your other observations such as the character of the amniotic fluid, the number of contractions in 10 minute period, the FHR per minute, whether the mother voided or not, her axillary temperature in centigrade, her pulse rate per minute, her BP, whether the patient is on oxytocin or not, and the patient�s other problems if any.As I have said below the colored part is where you are supposed to write your other observations such as the character of the amniotic fluid, the number of contractions in 10 minute period, the FHR per minute, whether the mother voided or not, her axillary temperature in centigrade, her pulse rate per minute, her BP, whether the patient is on oxytocin or not, and the patient�s other problems if any.

33. IV. Other findings to note (and record) during IE Status of membranes, write � I � if intact If ruptured, note color of amniotic fluid, write � C � if clear � M � if meconium stained � A � if absent � B � if bloody

34. Monitor every 4 hours*and record the findings Blood Pressure Pulse rate Temperature Urine voided (yes or no)

35. Monitor more frequentlyand record the findings Number of contractions in 10 minute period Fetal heart rate in 1 full minute The findings for these should be recorded every hour.The findings for these should be recorded every hour.

36. If woman is admitted in LATENT PHASE of labor (less than 4 cm dilated) � record only other findings (BP, FHT etc). If she remains in latent phase for next 8 hours (labor is prolonged), transfer her to hospital.

37. EXERCISES Indicate whether the progress of labor in the following partographs are normal or abnormal.

38. NormalNormal

39. AbnormalAbnormal

40. NormalNormal

41. EXERCISES Plot the observations in the following cases.

42. Case 4: A G2P1 was admitted at 2 am, IE showed a 4cm dilated cervix. The patient was still smiling and she was hesitant to be admitted. At 6 am, another IE was done � 8 cm dilated cervix, 80% effaced, station 0. At 8 am, fetal head was bulging at the perineum. Give the participants 3-5 minutes to answer this exercise.Give the participants 3-5 minutes to answer this exercise.

43. Check the answers individually.Check the answers individually.

44. Case 5: A G4P2 was referred at 5 pm. The midwife said that the patient is at 4 cm cervical dilatation. At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, 50% effaced, station -1, intact BOW. Give the participants 3-5 minutes to answer this exercise.Give the participants 3-5 minutes to answer this exercise.

45. Check the answers individually.Check the answers individually.

46. RECAP Significance and use of the partograph Parts of the partograph and information contained in it Recording or plotting of clinical observations Interpretation of the recorded findings and decision on referral An ounce of prevention is better than a pound of cure.An ounce of prevention is better than a pound of cure.

47. Remember this my dear MidwivesA job title alone does not make a person a leader. Only a person�s behavior determines if he or she occupies a leadership position. 

48.  Fellow Midwives, Colleagues Good day & Congratulations !!!