Lesson plan 13– Labour: Partograph - plotting and interpretation

Subject Midwifery

Unit ANM Syllabus unit VI: Normal labour- Partograph in the management of normal labour
GNM Syllabus unit V:Nursing management of women in labour- A. Monitoring of maternal and fetal
condition
Topic Labour : Partograph – plotting and interpretation

Group II Year ANM Students/III Year GNM Students

Place Virtual classroom, ANM/GNM Schools of the project

Time 2 hours

Teaching method Illustrated lecture cum discussion

Case studies
AV aids/instructional aids Power Point presentation and the entire virtual classroom equipment
Teaching partograph, Case studies and partograph sheets.
Student’s knowledge The students will have knowledge regarding the physiology of normal labour
pre- requisite
General objective At the end of the session the students will be able to describe about the partograph its plotting and
interpretation and develop the necessary skills to monitor a woman in labour with the help of the
partograph in the hospital and community settings.
Specific objectives At the end of the session the students will be able to
 List the parameters to be noted on the partograph while monitoring labour
 Explain the interpretation of the plotting on the partograph for FHS, cervical dilatation,
Uterine contractions, leaking, temperature and BP
 Practice plotting of partograph with the help of case studies
Review (5 mins) Ask the following questions to assess their understanding of the previous session:
 Define the first stage of labour.
 What is the duration of the first stage of labour?
 Introduction (5 mins) Narrate the following: to monitor the growth of an individual, we have growth charts. Likewise, to
monitor the progress of labour, we have a very important and useful tool called the partograph. After
various revisions from its time of inception, now we have the simplified partograph approved by the
government of India. In todays’ session we will learn how to plot the partograph and interpret it. The
objectives of this session are to list the parameters to be noted on the partograph while monitoring labour,
explain the interpretation of the plotting on the partograph for FHS, cervical dilatation, Uterine
contractions, leaking, temperature and BP and practice plotting of partograph with the help of case
studies.
S.N Time Specific Content Teaching learning
o objective activity
1. 30 List the Partograph Describe with the PPT
mins parameters to  The partograph is a graphic recording of the progress of active labour and the slides 5-15.
be noted on condition of the mother and foetus. It is a tool which helps assess the normal Display the large
the partograph progress of labour, need for action such as the early identification for the teaching partograph and
while need for referral. This facilitates timely referral to save the life of the mother explain each part of it.
monitoring and fetus. Distribute a copy of
labour Points to remember while plotting the partograph: partograph to the
 Begin plotting on the partograph only when active labour starts. Active labour students and discuss its
starts when the cervical dilatation is 4 cm or more and the woman is having at features.
least two good contractions every 10 minutes.
 Plot the first recording of cervical dilatation on the Alert line. Write the time What is active stage of
accordingly in the corresponding row for time. first stage of labour?
 Mark the time in the partograph in hours – Remember that each of the small
boxes in the vertical column of the partograph represents a half-hour interval
Plotting the partograph:
The following information can be monitored and recorded in the partograph:
 Identification data: This will help us to identify the woman in labour, her age,
Gravida and parity, her registration number, her husband’s name, date and
time of rupture of membranes, and date and time of admission
 Fetal condition:
 Fetal heart rate-This is recorded every half an hour. The rate should be
preferably counted immediately after a uterine contraction. The normal FHR
ranges from 120 to160 beats/minute. The dots at each reading should be
joined with a straight line with the previous reading to form a pattern. The two
 dark horizontal lines which mark the normal range of the FHS. The moment
they are out of these lines on any side, it is an alert to the provider to identify
the reason and refer if required. How often should the
 Amniotic fluid- Note the condition of the membranes and observe the colour fetal heart rate be
of the amniotic fluid as visible at the vulva every half an hour.When the monitored?
membranes rupture ,the time should be noted in the identification data section.
Record in the partograph as follows:
 Membranes intact (mark ‘I’)
 Membranes ruptured:
 Clear liquor (mark ‘C’)
 Meconium-stained liquor (mark ‘M’)
.
Labour progress:
Cervical dilatation:
 Record the cervical dilatation in centimeters every four hours.
 In this phase, cervical dilatation progresses by approximately 1 cm per hour
and is often quicker in multigravida.
How often should we
Plot the first recording of cervical dilatation on the Alert line. Write the time
look for the cervical
accordingly in the corresponding row for time. After four hours, conduct a
dilatation?
vaginal examination and plot the cervical dilatation in centimeters on the
graph. Mark the reading with an “X” sign over the point of intersection of the
time and length of cervical dilatation. The cross marking at each reading
should be joined with a straight line with the previous reading to form a
pattern
Uterine contractions:
 Chart the contractions every half an hour; count the number of contractions
over 10 minutes and note their duration in seconds. Record the number of
good uterine contractions (lasting more than 20 seconds) in 10 minutes every
half an hour and accordingly, blacken the boxes on the partograph.

 If the contraction is less than 20 seconds

 If the contraction is between 20-40 seconds

  If the contraction is more than 40 seconds

Interventions
 Mention any drug that has been administered during labour, including the
dosage, route and time of administration. Also include the food items and
liquids consumed by the woman during labour.It helps the provider to know
when she has taken the food and whether her stomach needs to be emptied by
ryles tube or not to avoid any complication during the immediate
postoperative period if general anaesthesia is given for LSCS.
Maternal condition:
 Record the maternal pulse on the graph every half an hour and mark with a
dot (.).
 Record the woman’s blood pressure on the graph every four hours, using a
vertical arrow ( )with the upper end of the arrow signifying the systolic blood
pressure and the lower end indicating the diastolic blood pressure.
 Record the temperature every four hours and note it on the temperature graph
in degree centigrade.
2. 30 Explain the Interpretation of the partograph: Explain with the PPT
mins interpretation  The normal FHR is 120-16- beats per minute. If the FHR is below 120 beats slides 16-17.
of the plotting per minute or above 160 beats per minute, it indicates foetal distress and
on the needs referral. This is indicated by the two dark horizontal lines which mark
partograph for
the normal ranges of FHR and the provider needs to be alert to the markings
FHS, cervical
dilatation, which are out of these two lines. If the FHR goes out of these lines on either
Uterine side, it is an alert to the provider to identify the reason and refer if required.
contractions,le  If the amniotic fluid is meconium stained it indicates fetal distress and hence
aking, referral.
temperature  If the Alert line is crossed (the plotting moves to the right of the Alert line), it
and BP
indicates prolonged/obstructed labour and you should be alert that something
is abnormal with the labour.
 Note the time when the Alert line is crossed. The woman needs to be referred
urgently to the FRU. Please remember to send the partograph along.
Crossing of the Action line (the plotting moves to the right of the Action line)
indicates the need for intervention. There is a difference of four hours
between the Alert line and the Action line. By the time the Action line is
crossed, the woman should ideally have reached the FRU for the appropriate
intervention. Refer as soon as Alert line is crossed and do not wait for referral
till the Action line is crossed.
 If there is no progress of the uterine contractions in terms of intensity,
frequency and duration, refer to the FRU.
 Referral to the FRU should be done if the woman’s vital signs increase or
drop from the normal level.

Indications for referral to the FRU on the basis of the partograph

 If the FHR is <120 beats/minute or >160 beats/minute
 If there is meconium- and/or blood-stained amniotic fluid
 When the cervical dilatation plotting crosses the Alert line (moves towards the
right side of the Alert line)
 If the contractions do not increase in duration, intensity and frequency.
 If the maternal vital signs, i.e. the pulse (more than 100/min), BP (>140/90
mmHg) and temperature (>38o C), cross the normal limit
3. 30 Practice Students practice plotting of partograph with the help of case studies Have 21 copies of the
mins plotting of Case study 1,2,3 case studies and 63
partograph copies of the blank
with the help partograph ready for 20
of case studies students.
Give the case studies
and the blank
partographs to the
students and ask them
to plot the partograph
and interpret it. When
everyone has finished it
show the filled in
partographs and
discuss.

Summary: (5 mins)
Summarize the points covered in the session – What are the information monitored and recorded in the partograph and
What are the points to remember while plotting the partograph

Discussion: (5 mins)
Provide time for the students to ask questions and clarify doubts.
Assignment / Application: (5 mins)
When the students are posted in the labour room, ask them to monitor a woman in labour using a partograph and submit the report to the
faculty incharge in the ANM/GNM schools for evaluation.
Evaluation: (5 mins)
1. When will you start plotting the partograph?
2. How often should you do a PV examination for labour progress?
3. What is the normal fetal heart rate?
4. When will you refer the woman based on the amniotic fluid?
5. How often should you monitor the blood pressure for the woman?
Answers key:
1. When the woman is in active phase of labour.i.e. cervical dilation of 4 cm or more
2. Every 4 hourly
 3. 120 to 160 beats per minute
4. If there is meconium
5. Every 4 hourly

Bibliography:
1. Diane M. Fraser, Margaret A. Cooper , Myles Textbook for Midwives (15th .ed.). Edinburgh: Churchill Livingston Elsevier, 2009.
2. A M Chalkley (2009), A textbook of the Health Worker Volume I (2nd ed.). New Delhi: New Age International Publishers
3. Guidelines for Antenatal Care and Skilled attendance at birth by ANMs/LHVs/SNs, Ministry of Health and Family Welfare, GoI, April
2010
4. A Handbook for Auxiliary midwives, Lady Health Visitor and Staff Nurses , Ministry of Health and Family Welfare, GoI, April 2010
5. Jacob Annamma, A comprehensive textbook of midwifery and gynaecological nursing (3rd edition). New Delhi : Jaype brothers medical
publishers., 2012.

Annexure - Case study: (Case study 1, 2, 3 in SBA handbook)

Case study: 1

Radha (wife of Gangaram), 26 years of age, third gravida, was admitted at 5:00 am on 11 June 2009 with the complaint of labour pains
since 2:00 am. Her membranes had ruptured at 4:00 am. She has two children of the ages of 5 and 2 years. On admission, her cervix was
2 cm dilated.
Plot the following findings on the partograph:
At 09:00 am: The cervix is dilated 5 cm.
• She had 3 contractions in 10 minutes, each lasting 20–40 seconds.
• The FHR is 120 beats per minute.
• The membranes have ruptured and the amniotic fluid is clear.
• Her BP is 120/70 mmHg.
• Her temperature is 36.8°C.
• Her pulse is 80 per minute.
9:30 am: FHR 120, contractions 3/10 each 30 seconds, pulse 80/minute, amniotic fluid clear
10:00 am: FHR 136, contractions 3/10 each 35 seconds, pulse 80/minute, amniotic fluid clear
10:30 am: FHR 140, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:00 am: FHR 130, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:30 am: FHR 136, contractions 4/10 each 45 seconds, pulse 84/minute, amniotic fluid clear
12:00 noon: FHR 140, contractions 4/10 each 45 seconds, pulse 88/minute, amniotic fluid clear
12:30 pm: FHR 130, contractions 4/10 each 50 seconds, pulse 88/minute, amniotic fluid clear
1:00 pm: FHR 140, contractions 4/10 each 55 seconds, pulse 90/minute, temperature 37°C, BP 100/70 mmHg, amniotic fluid clear
At 1:00 pm: - Cervix fully dilated
-Amniotic fluid clear
- BP 100/70 mmHg
At 1:20 pm: Spontaneous birth of a live female infant weighing 2.85 kg

Case study : 2

Rani (wife of Rambhajan), 18 years of age, was admitted at 10:00 am on 11 June 2009 with complaints of labour pains since 7:00 am.
This is her first pregnancy. Plot the following findings on the partograph:

At 10:00 am: • The cervix is dilated 4 cm. She had 2 contractions in 10 minutes, each lasting less than 20 seconds.
• The FHR is 140 per minute.
• The membranes are intact.
• Her BP is 100/70 mmHg.
• Her temperature is 37°C.
• Her pulse is 80 per minute.
10:30 am: FHR 140, contractions 2/10 each 20 seconds, pulse 90/minute
11:00 am: FHR 136, contractions 2/10 each 20 seconds, pulse 88/minute
11:30 am: FHR 140, contractions 2/10 each 20 seconds, pulse 84/minute
12:00 noon: FHR 136, contractions 3/10 each 30 seconds, pulse 88/minute, membranes ruptured, amniotic fluid clear
12:30 pm: FHR 146, contractions 3/10 each 35 seconds, pulse 90/minute, amniotic fluid clear
1:00 pm: FHR 150, contractions 4/10 each 40 seconds, pulse 92/minute, amniotic fluid meconium-stained
1:30 pm: FHR 160, contractions 4/10 each 45 seconds, pulse 94/minute, amniotic fluid meconium-stained
At 2:00 pm:
• Cervix dilated 6 cm
• Amniotic fluid meconium-stained
• Contractions 4/10 each 45 seconds
• FHR 162/minute
• Pulse100/minute
• Temperature 37.6°C
• BP 130/80 mmHg.
What action would you take in Rani’s case?

Case study : 3

Rubina (wife of Zarif), age 26 years, was admitted at 11:00 am on 12 June 2009 with the complaint of labour pains since 4:00 am. Her
membranes ruptured at 9:00 am. She has three children, of the ages of 8, 7 and 2 years. She gave birth to a stillborn child four years ago.
Plot the following findings on the partograph:
At 11:00 am:
• The cervix is dilated 4 cm.
• She had 3 contractions in 10 minutes, each lasting less than 20 seconds.
• The FHR is 140 per minute.
• The membranes have ruptured and the amniotic fluid is clear.
• Her BP is 100/70 mmHg.
• Her temperature is 37°C.
• Her pulse is 80 per minute.
11:30 am: FHR 130, contractions 3/10 each 35 seconds, pulse 88/minute, amniotic fluid clear
12:00 am: FHR 136, contractions 3/10 each 40 seconds, pulse 90/minute, amniotic fluid clear
12:30 pm: FHR 140, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
1:00 pm: FHR 130, contractions 3/10 each 40 seconds, pulse 90/minute, amniotic fluid clear
1:30 pm: FHR 120, contractions 3/10 each 45 seconds, pulse 96/minute, amniotic fluid clear
2:00 pm: FHR 118, contractions 3/10 each 45 seconds, pulse 96/minute, amniotic fluid clear
2:30 pm: FHR 112, contractions 3/10 each 45 seconds, pulse 98/minute, amniotic fluid meconium-stained
3:00 pm: FHR 100, contractions 4/10 each 45 seconds, pulse 100/minute, amniotic fluid meconium-stained, temperature 37.8°C, BP
120/80 mmHg, cervix dilated 7 cm.

What action would you take in Rubina’s case?