Definition

The partogram is a graphic display of progress

in labour .
It allows the an instant visual assessment of
the rate of cervical dilatation and comparison
with an expected norm ,according to the
parity of the woman ,so that slow progress
can be recognized early and actions taken to
correct it where possible .

Components
1) Identification data
-Name
-I/C
-RN
-Diagnosis
-Gravida
-Parity
-POA
-Date of Admission to Labour room
-Any significant antenatal complication
Components
2) Fetal component
-fetal heart rate
-liquor
-moulding
Components
3) Maternal component
-cervical dilatation
-descent of the head
-contraction
-pitocin/drugs/fluid given
-pulse and blood pressure
-temperature
-Urine (protein,sugar,acetone,volume)

Components

Components

HOW TO PLOT PARTOGRAPH
FETAL CONDITION ASSESSMENT
Fetal heart rate should be monitored every 30 min in first stage
and every 15 min in second stage of labour.
Membranes and liquor:
Intact membranes [I]
Ruptured membranes + clear liquor [C]
Ruptured membranes + meconium-stained liquor [M]
Ruptured membranes + blood-stained liquor [B]
Ruptured membranes + absent liquor [A]

Increasing molding with the head high in the pelvis is an ominous
sign of cephalo pelvic disproportion
Separated bones . sutures felt easily ..O
Bones just touching each other ..+
Overlapping bones ( reducible 0 ...++
Severely overlapping bones ( non reducible ) ..+++
Fetal conditions
Molding is an important indication of how adequately the
pelvis can accommodate the fetal head
PROGRESSION OF LABOUR
LABOUR 3 cm diltation OF CERVIX (lasts 8 hours or less.)
Once 3 cm diltation is reached , labour enters the active
phase, Cervix dilate at a rate of 1 cm / hour or faster.
Latent phase & Active phase

PROGRESS OF LABOUR
Dilatation of the cervix is plotted with (X).

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

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

ALERT LINE
Transfers from latent to active phase -the most
important feature is to transfer plotting of
cervical dilatation to the alert line.
Leaving the area between the transferred
recording blank.
Do not forget to transfer all other findings
vertically.

Descent of the fetal head
It should be assessed by abdominal examination immediately before doing a
vaginal examination, using the rule of fifth to assess engagement.
Assessing descent of the head assists in detecting progress of labor
The rule of fifth means the palpable fifth of the fetal head are felt by abdominal
examination to be above the level of symphysis pubis
When 2/5 or less of fetal head is felt above the level of ischial spine , this means
that the head is engage , and by vaginal examination , the lowest part of vertex has
passed or is at the level of ischial spines
Descent of the fetal head is plotted with (0).


DESCENT OF THE FETAL HEAD

Uterine contraction
Palpate number of contraction in ten minutes and duration of each
contraction in seconds
Observations of the contractions are made every hour in the latent phase
and every half-hour in the active phase
Frequency (how often are they felt)
Number of contractions in a 10 minutes period
Duration (how long do they last )
Measured in seconds from the time the contraction is first felt abdominally ,
to the time the contraction phases off
Each square represents one contraction
UTERINE CONTRACTION
Duration <20 sec:
Duration 20-40 sec:
Duration >40 sec:
MATERNAL CONDITION
Assess maternal condition regularly by monitoring :
Drugs , IV fluids , and oxytocin , if labour is augmented
Pulse , blood pressure
Temperature
Uterine volume , analysis for protein and acetone

Philpott and Castle partogram (1972):
introduce the concept of ALERT and
ACTION lines
ALERT line:
Drawn from 4cm of cervical dilatation to the point of
expected full dilatation at the rate of 1cm/hr
As long as dilatation is 1cm or more/hr the alert line is
not crossed
ACTION line:
Drawn 4 hours to the right of alert line and parallel to it
Critical line specific management division must be
made.

When labor is normally progress:
Normal Progress : on or to the left of alert line.
Do not intervene unless complications
develop
Do not augment with oxytocin if latent and
active phases go normally

When move to the right of the alert line:
WARNING
Transfer the woman from health center to
hospital
In hospital setting, continue vigilance monitoring
and observe labour progress
ARM may be performed if membranes are still
intact

At or beyond action line
Conduct carefully and do reassessments to find the cause of the
non-progressing and a decision made on further management
Options
Deliver by cesarean section if there is fetal distress or
obstructed labor
Augment with oxytocin by intravenous infusion if there are no
contraindications
Correction of malposition

KASMAN BIN JAAFAR
Interpretation of partograph
Component:
1. Fetal Condition:
Fetal Heart Rate
Membrane and Liquor
Moulding
2. Progress of Labour :
Cervical dilatation
Descent of the fetal head
Uterine contractions
3. Maternal condition :
Drugs , IV fluids , and oxytocin , if labour is augmented
Pulse , blood pressure
Temperature
Urine volume , analysis for protein and acetone



Interpreting:
This is a partograph of MrsS, G3P2 at
( POG) with (EDD)
At 9am:
-Fetal Heart rate was 120bpm, ruptured
membrane with clear liquour , no moulding
-Cervix was 5cm dilated, fetal head station - 3
(3/5)
- Uterine contraction was 4 in 10 minutes lasting
about (20-40 sec per contraction)
-No drugs was given
-Maternal pulse rate and blood pressure was 80
bpm and 110/70 mmhg respectively
- temperature was 36.8c
- Urine volume was 200ml, no presence of protein
or acetone.

At 1pm,
-Fetal heart rate was 150bpm, ruptured
membrane with clear liquor, no moulding
-Cervix was fully dilated ( 10cm), head was at
station 0, uterine contraction was 5 in 10 minutes,
with each contraction lasting > 40 sec.
-No drugs given, maternal vital sign normal, urine
150mls, no protein and acetone.
Live female infant was born at 1.20pm via
spontenous vaginal delivery with a birth weight
of 2.85kg. With APGAR score of 8, 10, 10
Normal pattern
The latent phase of labour should not last longer
than 8 hours.
The latent phase ends and the active phase starts
when her cervix is 3 cm dilated.
During the active phase cervix should dilate at not
less than 1 cm per hour.
For cervical dilatation, it should not move to the right
of the alert line or remain to the left of the alert line.
Abnormal labour
Labour becomes abnormal when there is poor
progress (as evidenced by a delay in cervical
dilatation (<2cm in 4hrs) or failure of descent
and rotation of fetal head) and/or the fetus
shows signs of compromise.
Plotting the findings of serial vaginal
examinations on partogram will help to
highlight poor progress in 1
st
stage of labour.


Abnormal progress
1. Prolonged latent phase
2. Primary dysfunctional labour
3. Secondary arrest

Prolonged latent phase
When the latent phase is longer than the
arbitrary time limits (>8 hours) .
Women with a prolonged latent phase risk
exhaustion and an increased risk of uterine
infection (chorioamnionitis)




Abnormal progress
Prolonged latent phase

Primary dysfunctional labour
Poor progress in active phase of labour (<1cm/hr
cervical dilatation)
Active phase last longer than 12 hours in a
primigravida and 6 hours in a multigravida
Aetiology
CephaloPelvic Disproportion
Fetal head malposition: OP/OT
Idiopathic
Excessive sedation


Secondary arrest
When progress in the active phase is initially good but
then slows, or stops altogether, typically after 7 cm
dilatation.
Results in flattening of the cervical dilatation curve
Aetiology
Secondary uterine inertia (common cause)
Exacerbated by epidural analgesia
Cephalopelvic disproportion
Fetal head malposition or malpresentation (breech)
Insufficient uterine action


Progress in labour is dependent on 3 variables
1. powers i.e. the efficiency of uterine
contractions eg. Inefficient uterine contraction
2. passenger, i.e. the fetus (with particular
respect to its size, presentation and position)
eg. Big baby, breech, brow presentation, OT, Op
position
3. passages, i.e. the uterus, cervix and bony
pelvis
Eg. Fibroid in lower segment of uterus
Cervical dystocia
Small pelvis, big baby (Cephalopelvic
disproportion, CPD)


Abnormal progress
Management
Rest
Encourage ambulation in latent stage.
Adequate hydration
Pain relief : morphine
Oxytocin stimulation
Amniotomy

Management
ARM followed by an oxytocin infusion is the
treatment of choice for primary dysfunctional
labour in a primiparous labour caused by poor
contractions or malposition.
Augmentation should only be commenced if
CTG or (FBS) is normal.

Great care must be exercised in the use of
oxytocin if CPD, malposition or malpresentation is
suspected in multiparous labour and it may
cause uterine rupture
Multiparous women with poor progress are
probably best treated by ARM and further time
to see if malposition or even malpresentation
corrects itself.
If progress fails to occur over the next 4-6 hours
of augmentation with syntocinon, CS will be
necessary.



Thank you.