--- Dr Shashwat Jani

WHY MONITOR?WHY MONITOR?

The intrapartum period is probably the The intrapartum period is probably the most dangerous and traumatic period – most dangerous and traumatic period – a time associated with a high mortality a time associated with a high mortality and morbidity for both mother and child.and morbidity for both mother and child.

Maternal and fetal monitoring are Maternal and fetal monitoring are essential to pick up problems early and essential to pick up problems early and thus institute timely intervention.thus institute timely intervention.

Eternal Eternal alertness for abnormalities alertness for abnormalities essential – essential – ““a labour is only said to a labour is only said to be normal after it is over”be normal after it is over”

INTRODUCTIONINTRODUCTION A A partograph partograph is a composite graphical record is a composite graphical record

of the observations made of a woman in of the observations made of a woman in labour labour on a single sheet of paperon a single sheet of paper..

It was developed and extensively tested by the It was developed and extensively tested by the World Health Organization (WHO 1994).World Health Organization (WHO 1994).

Can serve as an “Can serve as an “early warning systemearly warning system” & ” & assist in making timely decisions on transfers assist in making timely decisions on transfers (referrals), intervention (augmentation) &/or (referrals), intervention (augmentation) &/or termination of pregnancy.termination of pregnancy.

HISTORYHISTORY EmanuelEmanuel  Friedman'sFriedman's partograph - 1954 partograph - 1954 Based on observations of cervical dilatation Based on observations of cervical dilatation

and foetal station against time elapsed in hours and foetal station against time elapsed in hours from onset of labour. from onset of labour.

The time of onset of labour was based on the The time of onset of labour was based on the patient's subjective perception of her patient's subjective perception of her contractility. contractility.

Plotting cervical dilatation against time yielded Plotting cervical dilatation against time yielded the typical the typical SigmoidSigmoid or 'S' shaped curve, or 'S' shaped curve, and and station against time gave rise to the station against time gave rise to the HyperbolicHyperbolic curve. curve.

Philpott and Castle Philpott and Castle –– 1972 1972 Introduced concept of "Introduced concept of "ALERTALERT" and "" and "ACTIONACTION" "

lines. lines. Alert line Alert line was drawn at a slope of 1 was drawn at a slope of 1

centimetre/hr for nulliparous women starting centimetre/hr for nulliparous women starting at zero time i.e. time of admission . at zero time i.e. time of admission .

Action line Action line drawn four hours to the right of drawn four hours to the right of the alert line showing that if the patient has the alert line showing that if the patient has crossed the alert line active management crossed the alert line active management should be instituted within 4 hours, enabling should be instituted within 4 hours, enabling the transfer of the patient to a specialised the transfer of the patient to a specialised tertiary care centre. tertiary care centre.

Studd's labour stencils Studd's labour stencils - 1972- 1972 Five separate patterns representing Five separate patterns representing

normal labour progression were normal labour progression were constructed. constructed.

The curves were transcribed onto The curves were transcribed onto acrylic stencils.acrylic stencils.

OTHER PARTOGRAPHSOTHER PARTOGRAPHS

Hand drawn – Paper & Pencil.Hand drawn – Paper & Pencil. Round partograph.Round partograph. E – partograph.E – partograph.

PARTOGRAPHPARTOGRAPH

OBJECTIVESOBJECTIVES

Early detection of abnormal progress Early detection of abnormal progress of labour.of labour.

Prevention of prolonged labour.Prevention of prolonged labour. Recognize cephalopelvic Recognize cephalopelvic

disproportion long before obstructed disproportion long before obstructed labour.labour.

Assist in early decision on transfer, Assist in early decision on transfer, augmentation, or termination of augmentation, or termination of labour.labour.

OBJECTIVESOBJECTIVES (cont..) (cont..)

Increase the quality and regularity of all Increase the quality and regularity of all observations of mother and fetus.observations of mother and fetus.

Early recognition of maternal or fetal Early recognition of maternal or fetal problems.problems.

Highly effective in reducing complications Highly effective in reducing complications from prolonged labor for the mother from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn rupture and its sequelae) and for the newborn (death, anoxia, infections, etc). (death, anoxia, infections, etc).

Reduce incidence of CS rate.Reduce incidence of CS rate. Facilitates handover procedure.Facilitates handover procedure.

COMPONENTSCOMPONENTS

Part I Part I : Patient Identification: Patient Identification Part II Part II : Fetal condition: Fetal condition Part III Part III : Progress of labour: Progress of labour Part IV Part IV : Maternal condition: Maternal condition OutcomeOutcome ……………… ………………

Part I : Part I : PATIENT PATIENT IDENTIFICATIONIDENTIFICATION

NameName Gravida Gravida Para Para Hospital numberHospital number Date and time of admissionDate and time of admission Time of ruptured membranes.Time of ruptured membranes.

Part II : Part II : FETAL CONDITIONFETAL CONDITION

Monitor and assess fetal conditionMonitor and assess fetal condition

1 - Fetal heart rate1 - Fetal heart rate

2 - Liquor2 - Liquor

3 - Moulding the fetal skull bones3 - Moulding the fetal skull bones

FETAL HEART RATEFETAL HEART RATE Monitor every 30 mins in latent phase.Monitor every 30 mins in latent phase. Every 15 mins in active phase.Every 15 mins in active phase. Every 5 mins in 2Every 5 mins in 2ndnd stage of labour. stage of labour. Mark it with a dot & join the lines.Mark it with a dot & join the lines.Basal fetal heart rate?Basal fetal heart rate? << 160 beats/min =tachycardia 160 beats/min =tachycardia >> 110 beats/min = bradycardia 110 beats/min = bradycardia >>100100 beats/min = severe beats/min = severe

bradycardiabradycardia

MEMBRANES AND MEMBRANES AND LIQUORLIQUOR

Intact membranes Intact membranes ……………………………….. ……………………………….. II Ruptured membranes + clear liquor Ruptured membranes + clear liquor

……………… ……………… CC Ruptured membranes + meconium- stained Ruptured membranes + meconium- stained

liquor.. liquor.. MM Ruptured membranes + blood Ruptured membranes + blood –– stained stained

liquorliquor…… …… BB Ruptured membranes + absent Ruptured membranes + absent

liquorliquor…………………………. . A A

MOULDING THE FETAL MOULDING THE FETAL SKULL BONESSKULL BONES

Moulding is an important indication of how Moulding is an important indication of how adequately the pelvis can accommodate the fetal adequately the pelvis can accommodate the fetal head.head.

Increasing moulding with the head high in the Increasing moulding with the head high in the pelvis is an ominous sign of cephalopelvic pelvis is an ominous sign of cephalopelvic disproportion.disproportion.

Separated bones, sutures felt easilySeparated bones, sutures felt easily …………… ……………..… … OO Bones just touching each other Bones just touching each other …………………… …………………… ++ Overlapping bones (reducible)Overlapping bones (reducible)……………………………………... ... ++++ Severely overlapping bones (nonreducible) Severely overlapping bones (nonreducible) ………….. ..

++++++

Part III : Part III : PROGRESS OF PROGRESS OF LABOURLABOUR

Cervical dilatationCervical dilatation Descent of the fetal headDescent of the fetal head Uterine contractionsUterine contractions Fetal positionFetal position

This section of the partograph has as its This section of the partograph has as its central feature a graph with a vertical scale central feature a graph with a vertical scale on the left, numbered in the ascending order on the left, numbered in the ascending order from 0 to 10 (Cervical dilatation in cms). from 0 to 10 (Cervical dilatation in cms).

In same vertical scale – descent of the fetal In same vertical scale – descent of the fetal head as assessed by abdominal examination.head as assessed by abdominal examination.

At the right in the descending order denotes At the right in the descending order denotes the station of the fetal presenting part.the station of the fetal presenting part.

Horizontal scale represents hours spent in Horizontal scale represents hours spent in labour.labour.

Points are entered as a cross (x) for cervical Points are entered as a cross (x) for cervical dilatation & station by a dot (•). dilatation & station by a dot (•).

Each observation is joined to the preceding Each observation is joined to the preceding one by a straight line.one by a straight line.

The ‘S’ shaped dilatational curve is divided The ‘S’ shaped dilatational curve is divided into a latent phase and an active phase.into a latent phase and an active phase.

LATENT PHASELATENT PHASE

It starts from onset of labour until the cervix It starts from onset of labour until the cervix reaches 3 cm dilatation.reaches 3 cm dilatation.

Once 3 cm dilatation is reached, labour enters Once 3 cm dilatation is reached, labour enters the active phase.the active phase.

Lasts 8 hours or less.Lasts 8 hours or less.

At least 2/10 min contractions.At least 2/10 min contractions. Each lastingEach lasting < < 20 seconds.20 seconds.

ACTIVE PHASE ACTIVE PHASE

Contractions at least 3 / 10 minContractions at least 3 / 10 min Each lasting Each lasting << 40 seconds 40 seconds The cervix should dilate at a rate of 1 cm / The cervix should dilate at a rate of 1 cm /

hour or faster.hour or faster. Further subdivided into –Further subdivided into – Acceleration phase – 2.5 – 4 cms.Acceleration phase – 2.5 – 4 cms. Phase of maximum slope – 4 – 9 cms.Phase of maximum slope – 4 – 9 cms. Deceleration phase – 9 – 10 cms. Deceleration phase – 9 – 10 cms.

This can also be divided into 3 This can also be divided into 3 functional divisions – functional divisions –

1.1. Preparatory division Preparatory division – Including – Including latent & acceleration phase.latent & acceleration phase.

2.2. Dilatation division Dilatation division – Phase of – Phase of maximum slope.maximum slope.

3.3. Pelvic divisionPelvic division – Deceleration phase. – Deceleration phase.

ALERT LINEALERT LINE

The alert line drawn from 3 cm dilatation The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm/hour.represents the rate of dilatation of 1 cm/hour.

In a normal labour, cervical dilatation should In a normal labour, cervical dilatation should be either on the alert line or to the left of it.be either on the alert line or to the left of it.

Moving to the right of the alert line means it Moving to the right of the alert line means it falls on zone 2, it is abnormal & needs to be falls on zone 2, it is abnormal & needs to be critically assessed.critically assessed.

ACTION LINEACTION LINE The action line is drawn 4 hours to the The action line is drawn 4 hours to the

right of the alert line and parallel to it.right of the alert line and parallel to it.

This is the critical line at which specific This is the critical line at which specific management decisions must be made.management decisions must be made.

When it falls in zone 3 case should be When it falls in zone 3 case should be reassessed by a senior person. Decision to reassessed by a senior person. Decision to be made for CS or augmentation of labour. be made for CS or augmentation of labour.

CERVICAL DILATATIONCERVICAL DILATATION It is the most important information It is the most important information

and the surest way to assess progress and the surest way to assess progress of labour.of labour.

When progress of labour is normal and When progress of labour is normal and satisfactory, plotting of cervical satisfactory, plotting of cervical dilatation remains on the alert line or dilatation remains on the alert line or to left of it.to left of it.

If a woman arrives in the active phase If a woman arrives in the active phase of labour, recording of cervical of labour, recording of cervical dilatation starts on the alert line.dilatation starts on the alert line.

CERVICAL DILATATION CERVICAL DILATATION (cont..)(cont..)

When the active phase of labor begins, When the active phase of labor begins, all recordings are transferred and start all recordings are transferred and start by plotting cervical dilatation on the by plotting cervical dilatation on the alert line using the letters alert line using the letters TR.TR.

Leaving the area between the Leaving the area between the transferred recording blank. The transferred recording blank. The broken transfer line is not part of the broken transfer line is not part of the process of labor.process of labor.

Do not forget to transfer all other Do not forget to transfer all other findings vertically.findings vertically.

DESCENT OF THE FETAL DESCENT OF THE FETAL HEADHEAD

It should be assessed by abdominal It should be assessed by abdominal examination immediately before doing a examination immediately before doing a vaginal examination, using the vaginal examination, using the Rule of fifth Rule of fifth ( Crichton method ) ( Crichton method ) to assess engagement.to assess engagement.

The rule of fifth means the palpable fifth of The rule of fifth means the palpable fifth of the fetal head is felt by abdominal the fetal head is felt by abdominal examination above the level of symphysis examination above the level of symphysis pubis.pubis.

When 2/5 or less of fetal head is felt above When 2/5 or less of fetal head is felt above the level of symphysis pubis, this means that the level of symphysis pubis, this means that the head is engaged. the head is engaged.

DESCENT OF THE FETAL HEAD DESCENT OF THE FETAL HEAD (cont..)(cont..)

By vaginal examination, the lowest By vaginal examination, the lowest part of vertex has passed or is at the part of vertex has passed or is at the level of ischial spines in absence of level of ischial spines in absence of caput, is said to be caput, is said to be engaged head.engaged head.

FETAL POSITIONSFETAL POSITIONS

Occiput transverse positionsOcciput transverse positions

Occiput anterior positionsOcciput anterior positions  

UTERINE UTERINE CONTRACTIONSCONTRACTIONS

Palpate number of contractions Palpate number of contractions in ten minutes andin ten minutes and duration duration of of

each contraction in secondseach contraction in seconds

Less than 20 secondsLess than 20 seconds::  

Between 20 and 40 secondsBetween 20 and 40 seconds::

More than 40 seconds:More than 40 seconds:

Observations of the contractions are Observations of the contractions are made every hour in the latent phase and made every hour in the latent phase and every half-hour in the active phase.every half-hour in the active phase.

Assessed by number of contractions in Assessed by number of contractions in a 10 minutes period.a 10 minutes period.

Measured in seconds from the time the Measured in seconds from the time the contraction is first felt abdominally, to contraction is first felt abdominally, to the time the contraction passes off.the time the contraction passes off.

Each square represents one Each square represents one contraction.contraction.

Part IV: Part IV: MATERNAL MATERNAL CONDITIONCONDITION

Assess maternal condition regularly by Assess maternal condition regularly by monitoring:monitoring:

OxytocinOxytocin – Amount per volume IV – Amount per volume IV fluids in drops per minute, every 30 fluids in drops per minute, every 30 mins. Conc in upper box & dose mins. Conc in upper box & dose (mIU/min) in lower box. (mIU/min) in lower box.

DrugsDrugs – Any additional drugs given. – Any additional drugs given. IV FluidsIV Fluids – used. – used.

Part IV: Part IV: MATERNAL MATERNAL CONDITIONCONDITION

PulsePulse – Every 30 mins & marked with a – Every 30 mins & marked with a dot (•).dot (•).

Blood pressure Blood pressure – Recorded in vertical – Recorded in vertical line every 4 hours & marked with line every 4 hours & marked with arrows.arrows.

Temperature Temperature – Recorded every 2 hours.– Recorded every 2 hours. UrineUrine volume , analysis for protein and volume , analysis for protein and

acetone – Everytime urine is passed.acetone – Everytime urine is passed.

MANAGEMENT OF MANAGEMENT OF LABOUR USING THE LABOUR USING THE PARTOGRAPHPARTOGRAPH

- Latent phase is less than 8 - Latent phase is less than 8 hourshours

- Progress in active phase - Progress in active phase remains on or to the left of the remains on or to the left of the

alert line. alert line. Do not augment with oxytocin if Do not augment with oxytocin if

latent and active phases go latent and active phases go normally.normally.

No ARM in latent phase.No ARM in latent phase. ARM at any time in active phase.ARM at any time in active phase.

Between alert and action Between alert and action lines lines

In health center, the women must In health center, the women must be transferred to a hospital with be transferred to a hospital with facilities for caesarean section, facilities for caesarean section, unless the cervix is almost fully unless the cervix is almost fully dilated.dilated.

Observe labor progress for short Observe labor progress for short period before transfer.period before transfer.

Continue routine observations.Continue routine observations. ARM may be performed if ARM may be performed if

membranes are still intact.membranes are still intact.

At or beyond action lineAt or beyond action line

Conduct full medical assessment.Conduct full medical assessment. Consider intravenous infusion / Consider intravenous infusion /

bladder catheterization / analgesia.bladder catheterization / analgesia. OptionsOptions

- Deliver by caesarean section if there - Deliver by caesarean section if there is fetal distress or obstructed labour.is fetal distress or obstructed labour.

- Augment with oxytocin by - Augment with oxytocin by intravenous infusion if there are no intravenous infusion if there are no contraindications.contraindications.

ABNORMAL ABNORMAL PROGRESS OF LABORPROGRESS OF LABOR

“ “ One of the main functions One of the main functions of the partograph is to of the partograph is to detect early deviation detect early deviation

from normal progress of from normal progress of labor. “labor. “

Phases/ Stages of Phases/ Stages of labourlabour

NulliparoNulliparousus

MultiparoMultiparousus

Latent Latent phasephase

Mean Mean timetime

6.4 h6.4 h 4.8 h4.8 h

Longest Longest 20.1 h 20.1 h 13.6 h13.6 h

Active Active phasephase

Mean Mean raterate

3 cm/h3 cm/h 5.7cm/h 5.7cm/h

Slowest Slowest 1.2cm/h1.2cm/h

1.5cm/h1.5cm/h

22ndnd Stage Stage Mean Mean timetime

1.1 h1.1 h 0.4 h0.4 h

Longest Longest 2.9 h2.9 h 1.1 h1.1 h

LABOUR TIME FRAMESLABOUR TIME FRAMES

LATENT PHASELATENT PHASE Normal duration – 8hrs in Primi & Normal duration – 8hrs in Primi &

4hrs in Multi.4hrs in Multi. This is why there is a This is why there is a heavy line heavy line

drawn on the partograph at the end drawn on the partograph at the end of 8 hours of the latent phase.of 8 hours of the latent phase.

PROLONGED LATENT PROLONGED LATENT PHASEPHASE

It is prolonged when its duration It is prolonged when its duration exceeds 20 hrs in Primi & 14 hrs in exceeds 20 hrs in Primi & 14 hrs in Multi.Multi.

According to WHO partograph, a According to WHO partograph, a prolonged latent phase is “Cervix prolonged latent phase is “Cervix not dilated beyond 4cms after 8hrs not dilated beyond 4cms after 8hrs from admission & with any changes from admission & with any changes in cervical effacement or dilatation.”in cervical effacement or dilatation.”

PROLONGED ACTIVE PROLONGED ACTIVE PHASEPHASE

In the active phase of labor, plotting of In the active phase of labor, plotting of cervical dilatation will normally remain cervical dilatation will normally remain on or to the left of the alert line. on or to the left of the alert line.

Moves to the right of the alert line Moves to the right of the alert line warns that labor may be prolonged.warns that labor may be prolonged.

Happens Happens if the rate of cervical if the rate of cervical dilatation in active phase of labor is less dilatation in active phase of labor is less than 1cm/hour for a minimum of 4hrs.than 1cm/hour for a minimum of 4hrs.

At the action line, the woman must be At the action line, the woman must be carefully reassessed for why labor is carefully reassessed for why labor is not progressing and a decision made on not progressing and a decision made on further management.further management.

PROLONGED PROLONGED DECELERATION PHASEDECELERATION PHASE

Deceleration phase exceeds 3 hrs for Deceleration phase exceeds 3 hrs for nulliparas & 1 hour for multiparas.nulliparas & 1 hour for multiparas.

SECONDARY ARREST OF SECONDARY ARREST OF CERVICAL DILATATIONCERVICAL DILATATION

When the cervical dilatation When the cervical dilatation commences normally but stops or commences normally but stops or slows significantly for 2 hours or slows significantly for 2 hours or more prior to full dilatation of cervix.more prior to full dilatation of cervix.

SECONDARY ARREST OF SECONDARY ARREST OF HEAD DESCENTHEAD DESCENT

Abnormal progress of labor may Abnormal progress of labor may occur with normal progress of occur with normal progress of descent of the fetal head then descent of the fetal head then followed by secondary arrest of followed by secondary arrest of descent of fetal head.descent of fetal head.

Diagnostic CriteriaDiagnostic Criteria( In active labour)( In active labour)

For For Protracted dilatationProtracted dilatation, criteria are , criteria are

less than 1.2 cm per hour for primips less than 1.2 cm per hour for primips andand

less than 1.5 cm per hour for multips. less than 1.5 cm per hour for multips.

For For Protracted descentProtracted descent, the criteria are , the criteria are

less than 1.0 cm per hour in primips less than 1.0 cm per hour in primips and and

less than 2.0 cm per hour for multips.less than 2.0 cm per hour for multips.

PRECIPITATE LABOURPRECIPITATE LABOUR

- Maximum slope of dilatation of 5 - Maximum slope of dilatation of 5 cm/hr or morecm/hr or more

POINTS TO POINTS TO REMEMBERREMEMBER

It is important to realize that the It is important to realize that the partograph is a tool for managing partograph is a tool for managing labor progress only.labor progress only.

The partograph does not help to The partograph does not help to identifyidentify other risk factors that may other risk factors that may have been present before laborhave been present before labor started. started.

Only start a partograph when you have Only start a partograph when you have checked that there are no complications of checked that there are no complications of pregnancy that require immediate action.pregnancy that require immediate action.

A partograph chart must only be started A partograph chart must only be started when a woman is in labor -- be sure that she when a woman is in labor -- be sure that she is contracting enough to start a partograph.is contracting enough to start a partograph.

Fill up the patient details. Note the FHR & Fill up the patient details. Note the FHR & colour of liquor.colour of liquor.

If progress of labor is satisfactory, the plotting If progress of labor is satisfactory, the plotting of cervical dilatation will remain at or to the of cervical dilatation will remain at or to the left of the alert line.left of the alert line.

When labor progresses well , the dilatation When labor progresses well , the dilatation should not move to the right of the alert line.should not move to the right of the alert line.

The latent phase 0 The latent phase 0 –– 2 cm dilatation, is 2 cm dilatation, is accompanied by gradual shortening of cervix. accompanied by gradual shortening of cervix. Normally, the latent phase should not last more Normally, the latent phase should not last more than 8 hours.than 8 hours.

The active phase, 3 The active phase, 3 –– 10 cm dilatation, 10 cm dilatation, should progress at a rate of at least 1 should progress at a rate of at least 1 cm/hour.cm/hour.

When the woman arrives in the latent When the woman arrives in the latent phase, time of admission is 0 time.phase, time of admission is 0 time.

When admission takes place in the active When admission takes place in the active phase , the admission dilatation, is phase , the admission dilatation, is immediately plotted on the alert line.immediately plotted on the alert line.

Dilatation of the cervix is Dilatation of the cervix is plotted/recorded with a (x), descent plotted/recorded with a (x), descent of the fetal head is plotted with a (•) of the fetal head is plotted with a (•) and uterine contractions are plotted and uterine contractions are plotted with differential shading.with differential shading.

Descent of the head should always Descent of the head should always be assessed by abdominal be assessed by abdominal examination ( by the rule of fifths examination ( by the rule of fifths felt above the pelvic brim).felt above the pelvic brim).

Assessing descent of the head assists in Assessing descent of the head assists in detecting progress of labor.detecting progress of labor.

Increased moulding with a high head is Increased moulding with a high head is a sign of cephalopelvic disproportion.a sign of cephalopelvic disproportion.

Vaginal examination should be Vaginal examination should be performed infrequently as this is performed infrequently as this is compatible with safe practice (once compatible with safe practice (once every 4 hours is recommended).every 4 hours is recommended).

A woman whose cervical dilatation moves A woman whose cervical dilatation moves to the right of the alert line must be to the right of the alert line must be transferred and managed in an institution transferred and managed in an institution with adequate facilities for obstetric with adequate facilities for obstetric intervention, unless delivery is near.intervention, unless delivery is near.

When a woman’s partograph reaches the When a woman’s partograph reaches the action line, she must be carefully action line, she must be carefully reassessed to determine why there is lack reassessed to determine why there is lack of progress, and a decision must be made of progress, and a decision must be made on further management.on further management.

When a woman in labor passes the latent When a woman in labor passes the latent phase in less than 8 hours i.e., transfers phase in less than 8 hours i.e., transfers from latent to active phase, the most from latent to active phase, the most important feature is to transfer plotting important feature is to transfer plotting of cervical dilatation to the alert line of cervical dilatation to the alert line using the letters TR.using the letters TR.

Note down the oxytocin conc & dose, Note down the oxytocin conc & dose, drugs & iv fluids. Pulse, BP, Urine drugs & iv fluids. Pulse, BP, Urine examination & Temperature.examination & Temperature.

ELECTRONIC ELECTRONIC PARTOGRAPHPARTOGRAPH

A method of monitoring the A method of monitoring the progress of labor in a mother during progress of labor in a mother during childbirth, by attaching a position childbirth, by attaching a position sensor to a predetermined point on sensor to a predetermined point on the mother's pelvic bones; monitoring the mother's pelvic bones; monitoring the location of the position sensor in the location of the position sensor in three- dimensional space relative to a three- dimensional space relative to a reference; and monitoring the reference; and monitoring the location of the fetal presenting part location of the fetal presenting part with respect to the predetermined with respect to the predetermined point on the mother's pelvic bones.point on the mother's pelvic bones.

The location of the fetal presenting The location of the fetal presenting part may be indicated by a similar part may be indicated by a similar position sensor, or by imaging. position sensor, or by imaging. Other conditions, such as Other conditions, such as effacement, cervical dilatation, and effacement, cervical dilatation, and cervical position may also be cervical position may also be monitored in a similar manner.monitored in a similar manner.

Full electronic capture of patient Full electronic capture of patient information during childbirth information during childbirth including - including -

CTG, CTG, Partograph,Partograph, All labour events,All labour events, Outcome information. Outcome information.

Fetal blood sampling results and cord blood Fetal blood sampling results and cord blood gases direct from the blood gas analyzer.gases direct from the blood gas analyzer.

This information can be shown in real time This information can be shown in real time to enhance communication within and to enhance communication within and outside the delivery suite to improve outside the delivery suite to improve patient care and reduce human error.patient care and reduce human error.

It can be accessed from anywhere, anytime, It can be accessed from anywhere, anytime, from within a hospital or from home..from within a hospital or from home..

COMPUTERIZED LABOUR COMPUTERIZED LABOUR MANAGEMENTMANAGEMENTTo accurately and continuously measure To accurately and continuously measure cervical cervical dilatation and fetal head station in labor and the fetal dilatation and fetal head station in labor and the fetal monitoring and maternal monitoring.monitoring and maternal monitoring.An ultrasoundAn ultrasound––based computerized labor management based computerized labor management system was designed - system was designed - The Fetal Monitoring System and The Fetal Monitoring System and The Maternal Monitoring System withThe Maternal Monitoring System withThe system´s in-vivo generated individual Partographs The system´s in-vivo generated individual Partographs with real time dilatation and head station with real time dilatation and head station measurements. measurements.

The measurements had accuracy of ≤ 5mm.The measurements had accuracy of ≤ 5mm.

All parturients were comfortable throughout All parturients were comfortable throughout the insertion and the testing period. the insertion and the testing period.

There was no infection, bleeding or any There was no infection, bleeding or any significant local complication at any significant local complication at any attachment site. attachment site.

This system provides accurate continuous This system provides accurate continuous measurements of dilatation and station. measurements of dilatation and station.

The method is superior to digital examination The method is superior to digital examination and provides real time diagnosis of non-and provides real time diagnosis of non-progressive and precipitous labor. progressive and precipitous labor.

The system is likely to reduce discomfort and The system is likely to reduce discomfort and infections associated with multiple vaginal infections associated with multiple vaginal examinations.. examinations..

The Fetal Monitoring System The Fetal Monitoring System IIs a computer based training system s a computer based training system that can be accessed from anywhere, that can be accessed from anywhere, anytime, from within a hospital or anytime, from within a hospital or from a home.from a home.

The Maternal Monitoring System - The Maternal Monitoring System -

WHO PARTOGRAPHWHO PARTOGRAPH

The WHO partograph has been The WHO partograph has been modified in 2000 to make it simpler modified in 2000 to make it simpler and easier to use. and easier to use.

The latent phase has been The latent phase has been removed and plotting on the removed and plotting on the partograph begins in the active partograph begins in the active phase when the cervix is 4 cms phase when the cervix is 4 cms dilated.dilated.

Modified partograph - IndonesiaModified partograph - Indonesia – – 626 women; 20 midwives626 women; 20 midwives – – Referral rate increased Referral rate increased – – Fewer vaginal exams Fewer vaginal exams – – Fewer augmented labour Fewer augmented labour – – Fewer obstructed labour Fewer obstructed labour

(World Bank Tokyo April , 2010)

ADVANTAGESADVANTAGES Inexpensive technology which does Inexpensive technology which does

not malfunction.not malfunction. A picture is worth a thousand words.A picture is worth a thousand words. Helps in continuity of care and Helps in continuity of care and

providing information.providing information. Easy Handover Procedure.Easy Handover Procedure. No major capital investment other No major capital investment other

than skilled attendant.than skilled attendant.

Documented evidence for Documented evidence for Medico Medico Legal Legal purpose.purpose.

Educational value for all grades of Educational value for all grades of staff.staff.

DISADVANTAGESDISADVANTAGES

Assumes that all women progress at Assumes that all women progress at same ratesame rate

– – May influence intervention rate.May influence intervention rate. Clinical findings have subjective Clinical findings have subjective

variations.variations. Loss of clinical autonomy.Loss of clinical autonomy. Lack of knowledge.Lack of knowledge. Non availability of printed partographs.Non availability of printed partographs. Duplication of recording.Duplication of recording.