The Partograph

I. The Partograph
A

tool to help in management of labor

birth attendant to identify women whose labor is delayed and therefore decide appropriate action

Guides

OBJECTIVES
I.

To understand the concept of the WHO partograph

To explain to mothers the significance of the graph

II. To record the observations accurately on the graph III. To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral

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

The parts of the partograph

Progress of labor

Maternal and fetal well-being

D I L A T A T I O N

Alert line

D I L A T A T I O N

Alert line

Action line

Parallel and 4 hours to the right of alert line

Conditions that do 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

II. Recording the findings in the partograph

Start

by labeling the record with pertinent patient identifying information.

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)

Start plotting on alert line in the intersection corresponding cervical dilatation finding

4pm

Indicate the time the IE was made (and therefore, the observation was plotted)
Write this in the vertical line itself where you plot the X, NOT the space after it

X X

4pm

8pm

10pm

Perform internal examination every 4 hours, or more often if necessary, and plot findings each time
Also, do not forget to write the time each observation was made

X X

4pm

8pm

10pm

Connect the Xs to demonstrate the pattern of labor

EXAMPLE

x
1am

A G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix.

EXAMPLE
x

x
1am 5am

At 5 am, another IE showed 9 cm dilated cervix.

EXAMPLE
x x

x
1am 5am 7am

At 7 am, the patient is 10 cm dilated, intact BOW.

III. Distinguishing normal from abnormal labor pattern

X X X

4pm

6pm

8pm

10pm

Progress of labor is normal if plotting stays on or to the left of the alert line (green part)

4cm = active labor

4pm

6pm

8pm

10pm

Note that based on the structure of the partograph as soon as 4 cm is reached the cervix should dilate normally at a rate of 1 cm/hour.

X X

4pm

6pm

8pm

10pm

12am

2am

Plotting that passes the alert line (yellow part) more so if it reaches or passes the action line (red part) indicates abnormal progress of labor

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

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

Progress of labor

Maternal and fetal well-being

IV. Other findings to note (and record) during IE

Status If

of membranes, write

I if intact

ruptured, note color of amniotic fluid, write

C if clear M if meconium stained A if absent B if bloody

Monitor every 4 hours* and record the findings

Blood

Pressure Pulse rate Temperature Urine voided (yes or no)

* More frequently, if indicated

Monitor more frequently and record the findings

Number

of contractions in 10 minute period Fetal heart rate in 1 full minute

 If

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

If

EXERCISES
Indicate

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

Case 1

x
10pm 2am

Case 2
X X
8pm

12mn

2am

4am

Case 3

X X

9pm

1am

3am

EXERCISES
Plot

the observations in the following cases.

Case 4:
Maria, G2P1 was admitted today at 2 am, IE showed a 5cm dilated cervix, cephalic, intact BOW. BP=110/70, PR=88/min, afebrile. FHT=140/min. She had moderate contractions (3 in 10 min). At 6 am, the BOW ruptured with clear amniotic fluid. IE showed 8 cm dilated cervix. Vital signs were the same. At 8 am, cervix was 9 cm. She delivered spontaneously at 8:30 am. 10 u oxytocin was given IM. Placenta was delivered complete at 8:35 am.

Maria, G1P0 Date Today

X
2am

X X X

6am
0
C

8am

0 I 140 88
110/70

140 88

110/70

8:35

8:30

Case 5:
Lourdes, G4P2 was admitted at 1 pm today due to watery vaginal discharge. The cervix was 3 cm, cephalic, intact BOW. BP=120/80, PR=80/min, T-36.5. At 5pm, contractions were moderate, 3 in 10 min. IE showed cervix 4 cm dilated. Vital signs remained the same. At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, meconium stained fluid. BP-110/70, PR92/min, T-37.5, FHT-140/min

Lourdes, G4P2 Date Today

X
5pm

9pm

1am
0

3
80 120/80

3 36.5 120/80
80

M 37.5

36.5

92 110/70

Case 6:
Marites, G1P0 was admitted at 6 pm. BP=120/80, PR-84/min, T=36.5. FHT=150/min, cervix 5 cm dilated, (+) BOW. She had 2-3 uterine contractions in 10 min. After 4 hours, IE showed 7 cm dilated cervix. Vital signs and FHT were the same. At 12 am, another IE done showed 8 cm dilated cervix, negative BOW, clear AF. FHT= 140/min. Another IE after 2 hours was the same. FHT=144/min, Vital signs same

Marites, G1P0 Date Today

X
6pm

10pm

12am

2am
2

I 2-3 140 36.5 84 120/80 5

I 3 140 36.5 84 120/80 7

C 140

C 144 36.5 120/80 8

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