Partogram  The dilatation of Cx is plotted with an ‘X’.

Vaginal
 A Partogram is a graphical record of the observations examinations are done at admission and once in 4
made of a woman in labor hours
 For progress of labor and salient conditions of the
mother and fetus s
 It was developed and extensively tested by the world
health organization WHO

Overview
 The Partogram can be used by health workers with
adequate training in midwifery who are able to: Components of the Partogram:
- observe and conduct normal labour and  Part 1: fetal condition (at top)
delivery.  Part 11: progress of labour (at middle)
- Perform vaginal examination in labour and  Part 111: maternal condition (at bottom)
assess cervical dilation accurately  Outcome…
- plot cervical dilation accurately on a graph
against time
 There is no place for Partogram in deliveries at home
conducted by attendants other than those trained in
midwifery
 Whether used in health centers or in hospitals, the
Partogram must be accompanied by a program of
training in its use and by appropriate supervision and
follow up

Objectives:
 Early detection of abnormal progress of A 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
 The partogram can be highly effective in reducing
complications from prolonged labor for the mother
(postpartum hemorrhage, sepsis, uterine rupture,
and its sequelae) and for the newborn (death, anoxia,
infections, etc.).

Partogram functions:
 The partogram is designed for use in all maternity
settings, but has a different level of function at
different levels of health care
 In health center, the partogram 's critical function is:
 To give early warning if labour is likely
to be prolonged
 To indicate that the woman should be
transferred to hospital (ALERT LINE
FUNCTION) in hospital settings,
 Moving to the right of alert line serves
 as a warning for extra vigilance, but the action line is
the critical point at which specific management
decisions must be made
 Other observations on the progress of labour are also
recorded on the partogram and are essential features
in management of labour Part 1: Fetal condition
 this part of the graph is used to monitor and assess
fetal condition
STARTING OF PARTOGRAPH: 1 - Fetal heart rate
 partograph should be started only when a woman is 2 - membranes and liquor
in active phase of labour 3 - moulding the fetal skull bones
 Contractions must be 1 or more in 10mins, each Caput
lasting for 20secs or more
 Cervical dilatation must be 4cms or more

PARTOGRAPH:
 In the center of Partograph is a Graph. Along the left
side are numbers 0 -10 against squares. Each square
represents 1cm dilatation.
 Along the bottom of the graph are numbers
 0-24. Each square represents 1hour
Fetal heart rate:
 Basal fetal heart rate?
<160 beats/min = tachycardia
> 120 beats/min = bradycardia Latent phase:
 It starts from onset of labour until the cervix
 Decelerations? yes/no  reaches 3 cm dilatation
 Once 3 cm dilatation is reached,
 Relation to contractions?  labour enters the active phase
o Early  Lasts 8 hours or less
o Variable  contractions
o Late – -----Auscultation - return to  Each lasting < 20 seconds
baseline  At least 2/10 min
> 30 sec
*contraction Active phase:
----- Electronic  Contractions at least 3 / 10 min
monitoring  each lasting < 40 seconds
peak and trough  The cervix should dilate at a rate of 1 cm / hour or
(nadir) faster
> 30 sec
Alert line (Health Facility Line)
Membranes and liquor:  The alert line drawn from 3 cm dilatation
 intact  represents the rate of dilatation of 1 cm / hour
membranes………………………………………………………  Moving to the right or the alert line
I  means referral to hospital for extra vigilance
 ruptured membranes + clear
liquor……………………………..C Action line (hospital line)
 ruptured membranes + meconium- stained  The action line is drawn 4 hours to the right of the
liquor…………M alert line and parallel to it
 ruptured membranes + blood – stained  This is the critical line at which specific management
liquor………………B decisions must be made at the hospital
 ruptured membranes + absent liquor
………………………….A Cervical dilatation:
 It is the most important information and the surest
way to assess progress of labour, even though other
findings discovered on vaginal examination are also
important
 When progress of labour is normal and satisfactory,
plotting of cervical dilatation remains on the alert line
or to left of it
 If a woman arrives in the active phase of labour,
recording of cervical dilatation starts on the alert line
 When the active phase of labor begins, all recordings
are transferred and start by plotting cervical
dilatation on the alert line

Moulding the fetal skull bones:

 Moulding is an important indication of how
adequately the pelvis can accommodate the fetal
head
 increasing moulding 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 (reducible
0……………………….++
severely overlapping bones (non –
reducible) ….+++

Part-II – Progress of Labor:

 Cervical dilatation
 Descent of the fetal head
 Fetal position
 Uterine contractions Plotting the Descent of the Head:
 this section of the paragraph has as its central  On the left-hand side of the graph is the word
feature a graph of cervical dilatation against time “descent’ with lines going from 5 – 0
 it is divided into a latent phase and an active phase  Descent is plotted with an “O’ on the Partograph
 *Palpate number of contractions in ten minutes and duration
of each contraction in seconds:

 The width of the 5 fingers is a guide to the

expression in fifths of the head above the brim.
 A head that is mobile above the brim will
accommodate the full width of 5 fingers

Part III: Maternal Condition

 Assess maternal condition regularly by monitoring:
 Drugs, iv fluids, and oxytocin, if labour is augmented
 Pulse, blood pressure
 Temperature
 Urine volume, analysis for protein and acetone

 As the head descends, the portion of the head

remaining above the brim will be fewer fingers.

Who should not have a Partograph:

 Women with problems which are identified before
labor starts or during labor which need special
attention

Management of labour using the Partogram:

 Latent phase is less than 8 hours
 Progress in active phase remains on or left of the
alert line
 Do not augment with oxytocin if latent and active
phases go normally
Descent of the fetal head/Fifth’s Palpable:  Do not intervene unless complications develop
 Artificial rupture of membranes (ARM)
 No ARM in latent phase
 ARM at any time in active phase

Between alert and action lines:

 In health center, the women must be transferred to a
hospital with facilities for cesarean section, unless
the cervix is almost fully dilated
 Observe labor progress for short period before
transfer
 Continue routine observations
 ARM may be performed if membranes are still intact

At or beyond action line:

 Conduct full medical assessement
 Consider intravenous infusion
 bladder catheterization
 analgesia
 Options
 Deliver by cesarean section if there is fetal
distress or obstructed labour
Uterine contractions:
 Augment with oxytocin by intravenous
 Observations of the contractions are made every
infusion if there are no contraindications
hour in the latent phase and every half-hour in the
active phase
Oxytocin corrected uterine contractions:
 frequency how often are they felt?
 Assessed by 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
  One of the main functions of the Partogram is
to detect early deviation from normal progress
of labor

ABNORMAL PROGRESS OF LABOUR Prolonged Active phase:

 A woman whose cervical dilatation moves to the right
Moving to the right of alert line: of the alert line must be transferred and manged in a
 This means warning hospital with adequate facilities for obstetric
 Transfer the woman from health center to hospital intervention unless delivery is near
reaching the action line  At the action line, the woman must be carefully
 This means possible danger reassessed for why labor is not progressing and a
 Decision needed on future management (usually by decision made on further management
obstetrician or resident)

Prolonged latent phase:

 If a woman is admitted in labor in the latent phase
(less than 3 cm dilatation) and remains in the latent
phase for next 8 hours
 Progress is abnormal and she must br transferred to
a hospital for a decision about further action
 This is why there is a heavy line drawn on the
Partogram at the end of 8 hours of the latent phase

Secondary arrest of cervical dilatation:

 Abnormal progress of labor may occur in cases with
normal progress of cervical dilatation then followed
by secondary arrest of dilatation
Prolonged Active phase:
 In the active phase of labor, plotting of cervical
dilatation will normally remain on or to the left of the
alert line
 But some cases will move to the right of the alert line
and this warns that labor may be prolonged
 This will happen if the rate of cervical dilatation in
the active phase of labor is not 1 cm / hour or faster
  when labor goes from latent to active phase, plotting
of the dilatation is immediately transferred from the
latent phase area to the alert line

 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
 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 moulding with a high head is a sign of
cephalopelvic disproportion
 vaginal examination should be performed
Secondary arrest of head descant: infrequently as this is compatible with safe practice
 Abnormal progress of labor may occur with normal (once every 4 hours is recommended)
progress of descent of the fetal head then followed  when the woman arrives in the latent phase, time of
 by secondary arrest of descent of fetal head admission is 0 time
 a woman whose cervical dilatation moves to the right
of the alert line must be transferred and manged in
an institution with adequate facilities for obstetric
intervention, unless delivery is near
 when a woman’s Partogram reaches the action line,
she must be carefully reassessed to determine why
there is lack of progress, and a decision must be
made on further management (usually by an
obstetrician or resident)
 when a woman in labor passes the latent phase in
less than 8 hours i.e., transfers from latent to active
phase, most important feature is to transfer plotting
of cervical dilatation to the alert line using the letters
TR

CONCLUSIONS:
Precipitate Labour:  Evidence of efficacy of the partograph exists
 Maximum slope of dilatation of 5 cm/hr or more  When used correctly it improves maternal and
perinatal mortality rates
The Partogram in the management of labor following  Reinforcement of proper usage is encouraged
cesarean section.
 In women undergoing a trial of labor following
cesarean section
 the Partogramic zone 2-3 hr. after the alert line
represents a time of high risk of scar rupture.
 An action line in this time zone would probably help
reduce the rupture rate without an unacceptable
increase in the rate of cesarean section

SOME LIMITATIONS OFTHE PARTOGRAPH:

 Cervical dilatation assessment is imprecise
 No accurate timing of cervical dilatation assessment
 Frequency of examination varies
 Deviations from the 1cm/hour dilatation rate may be
normal
 Plotting of curves

Summary/Take Home Points:

 It is important to realize that the Partogram is a tool
for managing labor progress only
 The Partogram does not help to identify other risk
factors that may have been present before labor
started
 only start a Partogram when you have checked that
there are no complications of pregnancy that require
immediate action
 a Partogram chart must only be started when a
woman is in labor, be sure that she is contracting
enough to start a Partogram
 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
 the latent phase. 0 – 3 cm dilatation, is accompanied
by gradual shortening of cervix. Normally, the latent
phase should not last more than 8 hours
 the active phase, 3 – 10 cm dilatation, should
progress at rate of at least 1 cm/hour
 when admission takes place in the active phase, the
admission dilatation, is immediately plotted on the
alert line