PARTOGRAPH

I. The Partograph
 A tool for monitoring the progress of labor
 Guides birth attendant to identify women whose labor is delayed and therefore decide
appropriate action
 A partograph is a graphical record of the observation made of a woman in labor.
It is originally designed and used by Prof. R. H. Philpott in 1972 and modified, developed and
extensively tested by the World Health Organization (WHO).

In 1954, Friedman devised a partograph that was based on observations of cervical dilatation
and fetal station against time elapsed in hours in time of labor. The time onset of labor was
based on the patient’s subjective perception of her contractility.
o In1972, Philpott and Castle introduced the concept of “ALERT” and “ACTION” lines. The
alert line represented the mean rate of progress of the slowest 10% of patients in
African population whom they served.
The alert line was shown at a slope of 1 centimeter/hr for nulliparous women starting at zero
time i.e.time of admission.
The action line was drawn four hours to the right of the alert line. It shows that if the patient
has crossed the alert line, active management should be instituted within 4 hours, enabling the
transfer of the patient to a specialized tertiary care center.
Who can use the partograph?
 Usually, a midwife is responsible for recording the data on the progress of labor on a
partograph. However, trained health workers including nurses can also use a
partograph.
What are the legal responsibilities of health care workers using a partograph?
 Legally, health care workers who are using the partograph should:
o Provide correct entries
o Analyze and interpret findings correctly
o Record comprehensive data
o Truthfully record assessment data
o Observe and monitor clients accordingly
o Gather assessment data on time
o Refer clients appropriately when abnormalities are noted
o Act on abnormalities noted in the recordings
o Prevent further development of abnormalities noted in the recordings
o Have a thorough understanding of the implications of assessment findings

General Purpose of a partograph

1. In general, a partograph enables health care workers to detect abnormalities, potential
problems and possible augmentation of labor by facilitating the assessment and monitoring:
a. The pregnant client
b. The labor process
c. The fetus
More specifically, it is used by trained health workers to meet the following objectives
 Early detection of abnormal progress of labor.
 Prevention of prolonged labor.
 Recognize cephalopelvic disproportion long before obstructed labor.
 Assist in early decision on transfer, augmentation, or termination of labor.
  Increase the quality and regularity of all observations of mother and fetus.
 Early recognition of maternal or fetal problems.
 Reduction of complications from prolonged labor for the mother (postpartum
hemorrhage, sepsis, uterine rupture and its sequence0 for the newborn (death, anoxia,
infection etc.).
Advantages of using partograph:
1. Facilitates the assessment of labor, enabling health care workers to see the progress of labor
at a glance.
2. Facilitates decision making of health care provider for prompt referral of clients thereby
reducing the number of prolonged labor, oxytocin augmentation and caesarian delivery.
3. Reduces maternal mortality and morbidity related to obstructed labor.
Assessment Method and equipment when using partograph:
Assessment Method: PALPATION
Equipment:
 stethoscope – to auscultate the FHR towards the end of the uterine contraction to
detect slow recovery of the FHR back to baseline
 Handheld Doppler – to detect the FHR all throughout the contraction especially during
the contraction when the use of stethoscope becomes uncomfortable
 Cardiotograph machine – to provide a graphic record of the response of the fetal heart
rate to uterine activity including information on fetal heart rate and variability
COMPONENTS of a Partograph
1. The fetal record: data to be entered on the fetal record ; Fetal heart rate
2. The record of the progress of labor: data entered are a) cervical dilatation, b) descent,
c) uterine contractions
Cervical dilatation- represented by vertical scale 0-10
3. The maternal record
FETAL HEART RATE– represented by vertical graph with small squares labeled 100 to 180 at
intervals of 10.
 Assess the FHR before any of the following is done: a) artificial rupture of membrane b)
administration of anesthesia, c) administration of medication
 Assess after any of the following conditions: a) abnormal uterine contraction, b) rupture
of membranes, c) peak time of medication, d) administration of oxytocin
FHR – to be taken over a complete minute
auscultate every hour during latent phase, every 30 minutes during active phase,
every 15 minutes every fetal distress
Auscultation of the FHR must be made before and during the 30 seconds after a
contraction, in order to assess decelerations.
Decelerations – are slowing of the fetal heart rate below 120 beats per min
LIQOUR– refers to the condition of the amniotic fluid
How to record the condition of the amniotic fluid? (WHO graph)
Findings: Record on the partograph:
Intact membranes ___ I
Clear ____ C
Meconium stained ____ M
Absent _____ A
Bloody _____ B
Clear – normal; greenish – indicates meconium stained; muddy yellow color or slightly
greenish- indicate a previous event from which the fetus has recovered , this is common and
has no significance in post term babies.

MOULDING– refers to the overlapping of cranial bones. This means that the spaces between
the cranial bones are palpable. (WHO graph)
How to record moulding?
0 – separated bones, sutures are felt easily
+ - bones just touching each other
++ - overlapping bones (reducible)
+++ - severely overlapping bones (non palpable)

What are the indicators of the need for further interventions by the health worker, as reflected
on the fetal record?
 Late deceleration – indicate placental insufficiency. Placing the client on the left lateral
recumbent position and administration of oxygen are the priority interventions.
 Variable deceleration – may indicate cord compression. Place the client on the left
lateral recumbent position and administration of oxygen are the priority interventions.
 Increasing moulding with the head high in the pelvis, which is an ominous sign of
cephalopelvic disproportion
 A greenish liquor in a non-breech presentation which indicates meconium staining, a
sign of fetal distress.

What are the data entered on the Partograph on the progress of labor?
1. The record of the progress of labor: data entered are a) cervical dilatation, b) descent, c)
uterine contractions
Cervical dilatation- represented by vertical scale 0-10
2. The maternal record
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
II. Recording the findings in the partograph a rate of ≥ 1 cm/hour. (WHO & DOH graph)
•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 (4cm or more) and is contracting adequately (3-4
contractions in 10 min)
Start plotting on alert line in the intersection corresponding cervical dilatation finding
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
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
Connect the “X”s to demonstrate the pattern of labor

Conditions that does NOT need the use of partograph

•Antepartum hemorrhage
•Severe pre-eclampsia and eclampsia
•Fetal distress
•Previous cesarean section
•Multiple pregnancy
•Malpresentation
•Very premature labor
•Obvious obstructed labor
III. Distinguishing normal from abnormal labor pattern
Progress of labor is normal if plotting stays on or to the left of the alert line (green part)
Note that based on the structure of the partograph has soon as 4 cm is reached the cervix
should dilate normally at a rate of ≥ 1 cm/hour
 Start when woman is in ACTIVE LABOR (4 cm or more) and is contracting adequately (3-
4 contractions in 10 minutes)
 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 partograph passes ALERT LINE
•Reassess woman and consider referral.
•Alert transport services.
•Monitor intensively.

If partograph passes action line, refer urgently to an EmONC facility unless imminent delivery.

MATERNAL AND FETAL WELL BEING: (DOH graph)

IV. Other findings to note (and record) during IE
•Status of membranes, write
–“ I ”if intact
•If 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
Other findings:
Delivery of Placenta (Time)
Oxytocin (Time given)
Other problems-note/describe
If woman is admitted in LATENT PHASE of labor –record only other findings (BP, FHT etc).
If she remains in latent phase for next 8 hours (labor is prolonged), transfer her to hospital.
Quick action warranted in labor during following conditions
-Delay in cervical dilatation
-FHR < 120 or > 160/mt on 3 observation
-ROM and meconium stained liquor or absence
Record on WHO graph
Number of contraction in 10 minute period

Points to remember while using Partograph

 It is only a tool for managing labor progress
 Only start partograph who don’t have complications and doesn't require Referral
 Only be started when a woman is in labor
 If progress of labor is satisfactory, the plotting remain on/to the left of the Alert line
 Cervical dilation plotted as ‘X’
 Infrequent vaginal examination (every 4hrs) dilation moves to the right of the Alert line
must be transferred for obstetric interventions
 A woman whose cervical moves to the right of the alert line must be transferred for
obstetric interventions