Intrapartum Care & Partograph Monitoring Guide

1
Intrapartum Care &
Partograph
Session 2a
Care during labor and delivery
Maternal Health Division
Ministry of Health & Family Welfare
Government of India
BEMoC - Presentation 2 (a)

INTRAPARTUM CARE & PARTOGRAPH
Government of India
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Session Objectives
To learn about:
 How to conduct a normal labour
 Identify and manage complications during
labour
 How to plot a partograph

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TRUE & FALSE LABOUR PAINS
True labour pains False labour pains
Regular and predictable Irregular
Felt first in lower back & sweeps
towards lower abdomen
Remains confined to lower
abdomen
Not relieved by rest Often relieved by rest
Increase in duration , intensity
and frequency with time
Does not increase in
duration, intensity or
frequency
“Show” present “Show” absent
Accompanied by cervical changes Not accompanied by
cervical changes

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Stages of labour
First stage: From onset of labor till full dilatation
of cervix
 Latent Phase
• Cervix < 4 cms
• Contractions are weak
• Less than 2 contractions per ten minutes
 Active phase
• Cervix > or = 4 cms
• Contractions >3 per 10 min lasting 45 - 50
sec
• Rate of dilatation 1cm / hour or more
• Descent present

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Points to Remember
 Examine abdomen before vagina
 Do not shave perineum
 Wash hands,clean gloves,explain to the female
about PV
 If bleeding PV - PV not to be done
 Supine position with her legs flexed and apart

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 Cervical effacement
 Cervical dilatation in cms
 Presenting part
 Station and position of presenting part
 Status of membranes
 Color of liquor
During PV examination

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Supportive Care during Labour
 Keep woman informed of her progress
 Maintain privacy
 Encourage her to keep herself clean, wash
perineum
 Enema NOT ROUTINE: only if needed
 Empty bladder frequently

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Supportive Care during Labour
Presence of second person or birth
companion
Woman to be ambulatory
Woman free to choose any position
during labor & delivery
Hold her hand, massage back
Plenty of fluids, light fat free food

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Non Pharmacological pain relief
 Calm and gentle voice
 Offering encouragement, reassurance and
praise
 Relaxation techniques deep breathing
exercises and massage
 Assisting the woman in voiding urine and in
changing her position

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Stages of labour
Second stage: From full dilatation of cervix till
delivery of baby
 Full cervical dilatation
 Bulging thinned out perineum
 Gaping anus and vagina
 Head visible at the perineum

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Stages of labour
Third stage: From delivery of baby to delivery of
placenta
Fourth stage: For 2 hrs after delivery of the baby

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Monitoring of first stage of labour –
Latent phase
 Monitor every 1/2 hour
• Contractions:
 Frequency: How many contractions in 10 min
 Duration: Each lasting for how many seconds
• Fetal Heart Rate (FHR)
 Monitor the following every 4 hours: Temperature, pulse,
blood pressure
 Record time of rupture of membranes and color of
amniotic fluid.
 Emergency signs: Difficulty in breathing, shock, vaginal
bleeding

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Monitoring of First Stage of Labour
In Latent Phase
After 8 hours
Contractions stronger,
more frequent, no change
in dilatation or effacement
ROM +/-
REFER to FRU
Prolonged latent phase
No increase in intensity /
frequency / duration of
contractions, membranes not
ruptured and no progress in
cervical dilatation
Ask woman to relax

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Monitoring of first stage of labour –
Active phase
Monitor the following every 30 minutes:
 Maternal pulse, uterine contractions, FHR
 Look for presence of -
• Meconium or blood stained liquor or cord
prolapse
 Monitor the following every 4 hours:
• Cervical dilatation (in cm) by P/V
• Temperature
• Blood pressure

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Monitoring of First stage of Labour
In Active Phase
 Never leave the woman alone
 Monitor intensively using Partograph
 Refer immediately if no progress

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Partograph
What is a partograph?
 Graphic recording of the progress of labor
& condition of mother and fetus
 Labor record , thus reduces paper work
 Tool to identify complications of labor and
make timely referrals

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Filling a Partograph
Identification data
 Name
 Age,
 Parity,
 Date and time of
admission
 Registration
number;
 Time of rupture of
membranes.

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Fetal Condition
 Count fetal heart
rate every half hour
 Count for one full
minute, immediately
following a uterine
contraction
 Fetal distress:
 FHR <120
beats/minute or
>160 beats/minute
Arrange for referral

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Record status of membranes and
amniotic fluid in Partograph as follows:
 Membranes intact (mark ‘I’)
 Membranes ruptured (mark ‘R’)
 Clear liquor (mark ‘C’)
 Meconium stained liquor (mark ‘M’)

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Plotting a partograph
Labor
 Begin plotting in active
labor
 Cervical dilatation > 4
cms and > 2
contractions / 10
minutes
 Plot the initial finding.
Note the time.
 Repeat P/V after 4
hours and plot the
cervical dilatation

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Plotting a Partograph
Chart the contractions every half an hour
 Number of contractions in 10 mins
 Duration in seconds.
• Less than 20 seconds
• Between 20 and 40 seconds ////
• More than 40 seconds

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Maternal Condition
 Record maternal pulse
every half hour and mark
with a dot ( . )
 Record maternal BP
every 4 hours using a
vertical arrow, with upper
end signifying systolic
BP and lower end
diastolic BP
 Record the temperature
every 4 hours and note
on temperature graph

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Interventions
 Mention dose, route
and time of
administration of
any drug
 Mention the food
items and liquids
consumed

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 If Alert line is crossed
(the plotting moves to
the right of the alert
line) it indicates
abnormal labour :
prolonged/ obstructed
labour
 Note the time
 Refer patient to FRU
 Send partograph with
patient

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 Crossing of the Action line (the plotting
moves to the right of the Action line) :
indicates the need for intervention
 By the time the action line is crossed the
woman should ideally have reached the FRU
for the appropriate intervention to take place

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What are the indications for referral to FRU –
on the basis of partograph ?
 FHR is <120 beats / min or > 160 beats / min
 Meconium and /or blood stained amniotic fluid
 When cervical dilatation plotting crosses the
alert line (moves towards the right side of the
alert line)
 Contractions not increasing in duration,
intensity and frequency (e.g. < 2 contractions
lasting for < 20 sec in 10 min)

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Monitoring of second stage of labour
Monitor the following every 5 minutes
 Frequency,duration and intensity of
contractions
 FHR
 Perineal thinning and bulging
 Visible descent of foetal head during
contractions
 Presence of any signs indicating an
emergency

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Abdominal palpation
Watch for signs of imminent delivery
Gaping of vulva
Thinning and bulging of perineum
Pouting of anus
Head of the baby seen at vulva
Encourage the woman to push during
contractions when she has an urge to do so
while taking deep breaths

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Supportive management during second
stage
 Any position woman is comfortable: dorsal
lithotomy, tanding, sitting, squatting.
 Encourage bearing down when has urge to
push at full dilatation
 Discourage bearing down before the cervix is
fully dilated
 Do not ask her to hold breath
 Avoid ironing (sweeping and stretching) the
perineum

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2nd
stage management (contd...)
OXYTOCICS: not routinely recommended in
second stage.
EPISIOTOMY: not routine
 complicated vag. Delivery (malpresent)
 h/o third/fourth degree perineal tears
 foetal distress
 Instrumental/assisted delivery.

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2nd
stage management (contd...)
 Encourage rapid breathing with mouth open.
 Hydration- oral / IV fluids
 DO NOT apply fundal pressure
 5 clean’s- surface, hands, cord tie, blade,
cord stump
 Prepare for active mgmt. 3rd
stage

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Delivery of Head
 Ensure a controlled delivery of the head by
keeping one hand gently on the head and
other supporting the perineum
 Feel gently around the baby’s neck for
presence of umbilical cord
 If it is loose around the neck, deliver the baby
through the loop of the cord, or slip the cord
over the baby’s head
 If it is tight around the neck, doubly clamp and
cut in between

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Delivery of shoulders and rest of the body
 Wait for the spontaneous rotation and delivery
of the shoulders. This usually happens within
1-2 minutes
 Apply gentle pressure downwards to deliver
the top (anterior) shoulder
 Then lift the baby up, towards the mother’s
abdomen, to deliver the lower (posterior)
shoulder
 Deliver one shoulder at a time
 Rest of the baby’s body follows smoothly
 Note the time of birth

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Immediate postpartum care
 Fourth stage: first one hr after delivery.
 After placental delivery- check uterus well
contracted
 Examine perineum, lower vagina and vulva for
tears.
 Estimate the blood loss
 Clean the perineum
 Sanitary napkins

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Immediate postpartum care
 Dispose placenta in correct, safe and
culturally appropriate manner.
 Keep mother and baby together- encourage
early breastfeeding.
 Encourage woman to eat,drink and rest.
 Encourage woman to pass urine.
 Do not discharge the woman before 24 hours
after delivery.

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Postpartum
 Nutrition: advise to eat greater amount of foods
 Exclusive breastfeeding and rooming in
 Contraception: advise regarding birth spacing
or limitation.
 Registration of birth
 Postpartum visits- first at 7-10 days. Second at
6 weeks

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Key Messages
Let the woman choose a comfortable
position during labour and delivery
Maintain a partograph

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Moulding
Sutures apposed +
Sutures overlapped but reducible 2+
Sutures overlapped but not reducible 3+
Symbols
Cervix x
Head O
Breech w
Fetal heart rate .
Amniotic fluid
Membranes intact I
Membranes ruptures, clear fluid C
Meconium stained fluid M
Blood stained fluid B
1
WHO Managing complications in pregnancy and childbirth
PARTOGRAPH
Usual frequency of examination
Vaginal examination 4 hourly
Fetal Heart Rate ½ - ¼ hourly
Descent: Abdominal palpation1Descent: Abdominal palpation1
Contractions: Palpate abdomen (uterine fundus) over 10 min
Mild <20 seconds
Sutures overlapped but reducible 20-40 seconds
Sutures overlapped but not reducible >40 seconds

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Partograph Case 1
Name: Mrs KA
Hospital No.: 462432 XY
Age (Years): 20
Parity: Para 0 +0
Gestational age (Weeks): 38
Time
Cervix
(cm)
Membranes/
Liquor
Lie Presentation
FHR
(/Min.)
Moulding Descent
Contractions
(/10 Min.)
9am 2cm Intact longitudinal Cephalic 140 o 5/5
2 (<20
seconds)
History
• Lower abdominal pains
• No drainage of liquor
Time 9am
Pulse rate (/Min.) 90
Blood pressure (mmHg) 120/80
Temperature (o
C) 37.1o
Questions
• What actions will you take?
• How will you look after this
woman?

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Partograph Case 2
Name: Mrs AD
Age (Years): 18
Parity: Para 2+0
Time Cervi
x (cm)
Membranes/
Liquor
Lie Presentation FHR
(/Min.)
Moulding Descent Contractions
(/10 Min.)
4pm 4cm Intact longitudinal Cephalic 144 0 3/5 3 (35sec. each)
8pm 8cm Clear longitudinal Cephalic 146 0 2/5 4 (45 sec. each)
History
• Lower abdominal pains for 2 hours
• Drainage of liquor for 1 hour
Time 4pm 8pm
Pulse rate (/Min.) 88 90
Blood pressure (mmHg) 120/70 120/70
Temperature (o
C) 37o
37o
Questions
• What actions will you take
at 4pm?

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Partograph Case 2
Name: Mrs AD
Age (Years): 18
Parity: Para 2+0
Time Cervix
(cm)
Membranes/
Liquor
(/Min.)
(/10 Min.)
4pm 4cm Intact longitudinal Cephalic 144 0 3/5 3 (35sec. each)
8pm 8cm clear longitudinal Cephalic 146 0 2/5 4 (45 sec. each)
History
• Drainage of liquor for 1 hour
Time 4pm 8pm
Pulse rate (/Min.) 88 90
Blood pressure (mmHg) 120/70 120/70
Temperature (o
C) 37o
37o
Questions
at 4pm?
at 8pm?

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Partograph Case 3
Name: Mrs DG
Age (Years): 19
Parity: Para 0 +1
Time Cervix
(cm)
Membranes/
Liquor
Lie Present
ation
FHR
(/Min.)
Mouldi
ng
Desce
nt
Contractions
(/10 Min.)
6am 5cm Intact membranes longitudinal Cephalic 140 0 4/5 3 (40sec. each)
10am 5cm Artificial rupture of
membranes: clear
longitudinal Cephalic 146 0 3/5 2 (20sec. each)
12pm
(noon)
8cm clear Longitudina
l
Cephalic 140 0 2/5 2 (10 sec. each)
History
• No drainage of liqour
Time 6am 10am 12pm 2pm
Pulse rate (/Min.) 80 84 88 92
Blood pressure (mmHg) 130/70 130/70 140/70 140/70
Temperature (o
C) 37.3o
37 37.5 37.5
Questions
• What actions are
required?
• When would the next
examination be?

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Partograph Case 3
Name: Mrs DG
Age (Years): 19
Parity: Para 0 +1
Time Cervix
(cm)
Membranes/
Liquor
Lie Present
ation
FHR
(/Min.)
Mould
ing
Des
cent
Contractions
(/10 Min.)
membranes: clear
12pm (noon) 8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec. each)
History
Temperature (o
C) 37.3o
37 37.5 37.5
Questions
• Comment on the
partograph. What
actions are required?
examination be?

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Partograph Case 3
Name: Mrs DG
Age (Years): 19
Parity: Para 0 +1
Time Cervix
(cm)
Membranes/
Liquor
Lie Present
ation
FHR
(/Min.)
Moul
ding
Desc
ent
Contractions
(/10 Min.)
membranes: clear
12pm (noon) 8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec. each)
History
Temperature (o
C) 37.3o
37 37.5 37.5
Questions
• Comment on the
partograph. What
examination be?

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Partograph Case 3
Name: Mrs DG
Age (Years): 19
Parity: Para 0 +1
Time Cervi
x
(cm)
Membranes/
Liquor
Lie Presentat
ion
FHR
(/Min.)
Mouldi
ng
Desc
ent
Contractions
(/10 Min.)
membranes: clear
12pm
(noon)
8cm clear longitudinal Cephalic 140 0 2/5 2 (10 sec.
each)
2pm 9cm clear longitudinal Cephalic 144 0 2/5 2 (20 sec.
each)
History
Temperature (o
C) 37.3o
37 37.5 37.5
Questions
• Comment on the
partograph. What

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Partograph Case 4
Name: Mrs HA
Age (Years): 16
Parity: Para 0 + 0
Time Cervi
x (cm)
Membranes/
Liquor
Lie Presentati
on
FHR
(/Min.)
(/10 Min.)
10am 4cm Spontaneous
rupture, clear
L Cephalic 150 1 + 3/5 3 (30 sec.
each)
2pm 6cm Blood stained L Cephalic 156 2 + 3/5 4 (40 sec.
each)
4pm 6cm Meconium stained L Cephalic 164 3 + 3/5 4 (45 sec.
each)
History
• Labour at home for 6 hours
• Membrane ruptured 4 hours before admission
Time 10am 2pm 4pm
Pulse rate (/Min.) 80 86 92
Blood pressure (mmHg) 120/70 130/70 130/70
Temperature (o
C) 37 37.2 37.2
Questions
• Plot the information on a partograph.
• What action will you take?
• When would you perform the next
vaginal examination?

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Partograph Case 4
Name: Mrs HA
Age (Years): 16
Parity: Para 0 + 0
Time Cervix
(cm)
Membranes/
Liquor
(/Min.)
(/10 Min.)
10am 4cm Spontaneous
rupture, clear
L Cephalic 150 1 + 3/5 3 (30 sec.
each)
2pm 6cm Blood stained L Cephalic 156 2 + 3/5 4 (40 sec.
each)
4pm 6cm Meconium
stained
L Cephalic 164 3 + 3/5 4 (45 sec.
each)
History
Time1 10am 2pm 4pm
Blood pressure
(mmHg)
120/70 130/70 130/70
Temperature (o
C) 37 37.2 37.2
Questions
• Comment on the partograph.
• When would you perform the next
vaginal examination?
Maternal and Newborn Health Unit Liverpool School of Tropical Medicine
LSTM/RCOG Life Saving Skills –Essential (Emergency ) Obstetric Care
and Newborn Care

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Partograph Case 4
Name: Mrs HA
Age (Years): 16
Parity: Para 0 + 0
Gestational age
(Weeks):
39
Time Cervix
(cm)
Membranes/
Liquor
Lie Presenta
tion
FHR
(/Min.)
(/10 Min.)
10am 4cm Spontaneous rupture,
clear
L Cephalic 150 1 + 3/5 3 (30 sec. each)
2pm 6cm Blood stained L Cephalic 156 2 + 3/5 4 (40 sec. each)
4pm 6cm Meconium stained L Cephalic 164 3 + 3/5 4 (45 sec. each)
History
Time 10am 2pm 4pm
Temperature (o
C) 37 37.2 37.2
Questions
• What action will you take in a
BEOC and CEOC health facility
Maternal and Newborn Health Unit Liverpool School of Tropical Medicine
LSTM/RCOG Life Saving Skills –Essential (Emergency ) Obstetric Care and
Newborn Care

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Partograph Case 5
Questions
• You are called. What would you
do?
• When will you do another vaginal
examination?
Name: Mrs SA
Age (Years): 24
Parity: Para 3+1
Time Cervix
(cm)
Membranes/
Liquor
Lie Presentatio
n
FHR
(/Min.)
(/10 Min.)
10am 4cm Spontaneous rupture
2 hours ago, clear
L Cephalic 140 0 3/5 3 (30 seconds)
2pm 8cm Clear L Cephalic 156 1+ 3/5 3 (40 seconds)
History
• Lower abdominal pains 3 hours
• Drainage of liquor 2 hours
Time 10am 2pm 4pm
Temperature (o
C) 37o
37o
37

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Partograph Case 5
Questions
• What action would you take?
Name: Mrs SA
Age (Years): 24
Parity: Para 3+1
Time Cervi
x (cm)
Membranes/
Liquor
(/Min.)
(/10 Min.)
2 hours ago, clear
History
Time 10am 2pm 4pm
Blood pressure
(mmHg)
130/70 130/70 130/70
Temperature (o
C) 37o
37o
37

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Partograph Case 5
Questions
• What action will you take?
• What are the options for delivery?
Name: Mrs SA
Age (Years): 24
Parity: Para 3+1
Time Cervix
(cm)
Membranes/
Liquor
(/Min.)
(/10 Min.)
2 hours ago, clear
History
Time 10am 2pm 4pm
Temperature (o
C) 37o
37o
37

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Session 2a
Case Study No. …………….. 1-3
Page no……………………… 15-19
Answer to Case Study……… 125-127

Intrapartum Care & Partograph Monitoring Guide

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