Partograph

HARLEY L. DELA CRUZ MAN RN

Partograph
• Use partograph to monitor progress of
labour at all women admitted to labour
ward
• Women should not be admitted for labour
ward until in active labour
• Active labour is when women have regular
contractions (3-5 in ten minutes) and
cervix is 4 cm. dilated
WHO Partographs: Original and Simplified

Original WHO Partograph Simplified WHO Partograph

WHO Partographs: Differences

Original WHO Partograph Simplified WHO Partograph

 Components of the partograph
Fetal condition:
-fetal heart rate
-membranes and liquor
-moulding

Progress of labor:
-cervical dilation
-descent of the fetal head
-uterine contractions

Maternal condition:
-pulse, blood pressure, temperature
-urine
-drugs and IV fluids
-oxytocin regime
 Part 1 : Fetal condition
this part of the graph is used to monitor
and assess fetal condition:
1. Fetal heart rate
2. membranes and liquor
3. molding the fetal skull bones. Caput
Fetal Heart Rate:
• Assess after contraction for 60 seconds:
• Each 30 minutes in first stage (each 15
minutes if risk factors are identified
• Each 5 minutes when pushing
 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

Remember: the diagnosis “cephalopelvic

disproportion” cannot be made with intact
membranes!
 Molding the fetal skull bones
• Molding is an important indication of how adequately the
pelvis can accommodate the fetal head. Increasing
molding with the head high in the pelvis is an ominous
sign of Cephalopelvic disproportion.
• separated bones . sutures felt easily……….O
• bones just touching each other……………..+
• overlapping bones …………… …………...++
• severely overlapping bones ( notable ) ……..+++
 Part 2 : progress of labour
this section of the paragraph has as its central feature a graph
of cervical dilation against time

• Cervical dilatation
• Descent of the fetal head
• Uterine contractions

it is divided into a latent phase and an active phase

Cervical Dilatation
• Assessed each 4 hours (or before if a crossed
action line is anticipated)

Alert Line:
• Start recording cervical dilatation in the alert line.
• As long as dilatation is 1 cm or more/hr the alert
line is not crossed.
• If cervical dilatation is < 1 cm/hr the alert is
crossed and causes of prolonged labour should
be considered: always consider: artificial rupture
of membranes and augmentation with oxytocin.
Cervical dilatation
Action Line:
• If the action line is crossed the actions
should be as follows in mentioned order (if
not already performed)
• ARM and oxytocin augmentation
• Correction of malposition
• Cesarean Section or Vacuum (if in second
stage and descend is 1/5 or below)
 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

• 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 symphysis pubis , 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
 Assessing descent of the fetal head by
vaginal examination;
0 station is at the level of the ischial spine
Contractions:
Chart every 30 minutes
Number/10 minutes and Duration
• Weak: Lasting <20 seconds
• Medium: Lasting 20-40 seconds
• Strong: Lasting >40 seconds
Oxytocin:
• Record oxytocin (amount/volume) and
drops / minute
Dilatation of the cervix is plotted ( recorded with an X,
descent of the fetal head is plotted with an O , and
uterine contractions are plotted with differential
shading
 Part 3 : maternal condition
• pulse, blood pressure, temperature
• urine
• drugs and IV fluids
• oxytocin
Management of labour using
the partograph
 Diagnosis of labour

Regular painful contractions resulting in

progressive change of the Cervix
+/- show
+/- rupture of membranes
Components of normal labour
Patient
pain , bladder empty , dehydration , exhaustion
Powers
Uterine contractions
Maternal effort
Passages
Maternal pelvis ( Inlet - Outlet )
Maternal soft tissue
Passenger
Fetal ( size - presentation - position – Moulding)
cord
placenta
membranes
If labor progresses
“normally”:

• Do not need oxytocin

augmentation or other
intervetion, unless
complications develop.

• Can do ARM (artificial

rupture of membranes)
during active phase
If between Alert and Action Lines:
This means “warning”

• In health center, transfer to facility with C-section

capability, unless cervix is almost completely dilated.

• Observe labor progress for short period before

transfer.

• Continue routine observations.

• ARM can be performed if membranes are still intact.

If At or Beyond Action Line:
This means “danger” - - decision
needed on management by
obstetrician or resident.

• Conduct full medical

assessment
• Consider IV,
catheterization, pain
medication
• Deliver by C-section if
there is fetal distress or
obstructed labor
• Augment labor with
oxytocin by IV if there are
no contraindications
ABNORMAL PROGRESS OF LABOR
• One of the main functions of the
partograph is to detect early deviation
from normal progress of labor
Prolonged Active phase
Secondary arrest
of cervical
dilatation
Secondary arrest of head descent
 POINTS TO REMEMBER
• It is important to realize that the partograph is a
tool for managing labor progress only

• The partograph does not help to identify other risk

factors that may have been present before labor
started
• Only start a partograph when you have
checked that there are no complications of
pregnancy that require immediate action

• A partograph chart must only be started when

a woman is in labor, Be sure that she is
contracting enough to start a partograph
• If progress of labor is satisfactory, the plotting
of cervical dilatation will remain or to the left of
the alert line

• When labor progress well, the dilatation should

not move to the right of the alert line

• When admission takes place in the active

phase, the admission dilatation, is immediately
plotted on the alert line
• Descent of the head should always be assessed by
abdominal examination ( by the rule of fifths felt
above the pelvic brim ) immediately before doing a
vaginal examination

• Assessing descent of the head assists in detecting

progress of labor

• Increased molding with a high head is a sign of

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

• When the woman arrives in the latent phase ,

time of admission is 0 time

• A woman whose cervical dilatation moves to

the right of the alert line must be transferred
and managed in an institution with adequate
facilities for obstetric intervention , unless
delivery is near
• Oxytocin should be titrates
OXYTOCIN
against uterine contractions
and increased every half- hour
until contractions are 3 or 4
in10 minutes , each lasting 40 –
50 seconds

• Stop Oxytocin infusion if there

is evidence of uterine
hyperactivity and / or fetal
distress

• Augment with Oxytocin only

after artificial rupture of
membranes and provided that
the liquor is clear
 CASE STUDY: Mrs. A
Step 1:
• Mrs A. was admitted at 5:00 am on 5/9/2014
• Her membranes ruptured at 4:00 am
• Gravida 3, para 2
• Hospital number 567886
• On admission, the fetal head was 4/5 palpable
above the pelvic bone and the cervix was 2 cm
dilated.

What should we record on the partograph?

 CASE STUDY: Mrs. A
Step 2:

09:00 am
• The fetal head is 3/5 palpable above the
pubic bone
• The cervix is 5 cm dilated

What should we record on the partograph?

Mrs. A 3 2 567886
5/9/2014 5:00 a.m. 4:00 a.m.

x
o

9
 CASE STUDY: Mrs. A
• There are 3 contractions in 10 minutes, each lasting 20-
40 seconds
• Fetal heart rate (FH) is 120
• Membranes ruptured, amniotic fluid is clear
• Skull bones separated, sutures easily felt
• Blood pressure is 120/70
• Temperature is 36.8 C
• Pulse is 80 per minutes
• Urine output is 200 ml, negative protein and acetone

What steps should be taken? What advice should we

give?
What do we expect to find at 1:00 pm?
Mrs. A 3 2+0 7886
12.5.2000 5:00 a.m. 4:00 a.m.

C
1

x
o

9
 CASE STUDY: Mrs. A
Step 3
Plot the following information on the partograph:
• 09:30 a.m. FH 120, contractions 3/10 each 30 sec, Pulse 80
• 10:00 a.m. FH136, contractions 3/10 each 30 sec, Pulse 80
• 10:30 a.m. FH140, contractions 3/10 each 35 sec, Pulse 88
• 11:00 a.m. FH130, contractions 3/10 each 40 sec, Pulse 88, Temp
37
• 11:30 a.m. FH136, contractions 4/10 each 40 sec, Pulse 84, Head
is 2/5 up
• 12:00 pm FH140, contractions 4/10 each 40 sec, Pulse 88
• 12:30 pm FH130, contractions 4/10 each 45 sec, Pulse 88
• 1:00 pm FH140, contractions 4/10 each 45 sec, Pulse 90, Temp 37
 CASE STUDY: Mrs. A
1:00 pm
• Fetal head is 0/5 palpable above the pubic
bone
• Cervix is fully dilated
• Amniotic fluid clear
• Skull bones separated, sutures easily felt
• Blood pressure 100/70
• Urine output 150 ml; negative protein and
acetone
Mrs. A 3 2 567886

5/9/2014 5:00 a.m. 5

C
1
x

x
o

9 10 11 12 1
 CASE STUDY: Mrs. A

01:20 pm: spontaneous delivery of a live term female

 CASE STUDY: Mrs. B
Step 1:
• Mrs B. was admitted at 7:00 am on 3/7/2014
• Gravida 1, para 0
• Hospital number 679456
• On admission, the fetal head was 3/5 palpable
above the pelvic bone and the cervix was 4 cm
dilated.

What should we record on the partograph?

Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I
0

x
o

7
 CASE STUDY: Mrs. B
Step 2:

11:00 am
• The fetal head is 1/5 palpable above the
pubic bone
• The cervix is 5 cm dilated

What steps should be taken? What advice

should we give?
Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I C
0 1

x
x
o
o

7 8 9 10 11

10
 CASE STUDY: Mrs. B
Step 3:

13:00 am
• The fetal head is 0/5 palpable above the
pubic bone
• The cervix is 8 cm dilated

What steps should be taken? What advice

should we give?
Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I C C
0 1 1

x
x
o

o
o

7 8 9 10 11 12 13

1010
 CASE STUDY: Mrs. B
Step 4:

14:00 am
• The fetal head is 0/5 palpable above the
pubic bone
• The cervix is fully dilated
Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I C C C C C C C
0 1 1 1 1 1 1 1
x

x
x
o

o
o o

7 8 9 10 11 12 13 14

1010
 CASE STUDY: Mrs. B

02:30 pm: spontaneous delivery of a live term male

 CASE STUDY: Mrs. C
Step 1:
• Mrs C. was admitted at 10:00 am on 3/14/2014
• Gravida 1, para 0
• Hospital number 567745
• On admission, the fetal head was 4/5 palpable
above the pelvic bone and the cervix was 4 cm
dilated.
• Her membranes ruptured at 5:00 am
• FHT: 140
• Contractions 3/10 each 30 sec
Mrs. C 1 0 567745

3/14/2014 10:00 a.m. 5

C
1

o
x

10
 CASE STUDY: Mrs. C
Step 2:

2:00 pm
• The fetal head is 1/5 palpable above the
pubic bone
• The cervix is 5 cm dilated

What steps should be taken? What advice

should we give?
Mrs. C 1 0 567745

3/14/2014 10:00 a.m. 5

c c c c c c c c C
1 2

x
o o

10 11 12 13 14
 CASE STUDY: Mrs. C
Step 3:

5:00 pm
• The fetal head is 0/5 palpable above the
pubic bone
• The cervix is 5 cm dilated

What steps should be taken? What advice

should we give?
Mrs. C 1 0 567745

3/14/2014 10:00 a.m. 5

c c c c c c c c C C B B B M M
1 2 3

x x

x
o o o

10 11 12 13 14 15 16 17
 CASE STUDY: Mrs. C

17:30 pm: Cesarean section of a live term male

Thank you