Partogram

Professor Adel Abul-Heija FRCOG

What is a Partograph?
Definition: A tool to assess & interpret the progress
of labour.

The partograph is a means of graphic presentation

of labour:
– Progress of labour
 Cervical dilatation
 Foetal head descent
 Uterine contractions
– Foetal status
– Maternal status
RECORD
Record foetal condition including:
Foetal heart beat rate
Moulding of the foetal head
Condition of amniotic fluid
Record maternal condition:
Pulse and blood pressure
Body temperature
Urine (quantity, presence of protein and acetone)
Drugs administered including Oxytocin.
IV fluids.
Record progress of labor:
Cervical dilatation
Descent of the head
Uterine contractions:
History of the
Partograph:
WHO, 1988
The WHO Partograph, 1988
Benefits
 Effective standard for observing the progress of
labour
 Provides early detection for the unsatisfactory
progress of labour
 Detection of cephalopelvic disproportion before the
obstruction appears
 Helps to make quick and logical decisions for
managing labour
 Identifies the necessary interventions
 Simple, low cost, accessible and clear
Key Principles for Using the
Partograph
 The partograph is used to record mainly the active
first stage of labour
– However, after full cervical dilatation is reached, you
should continue to record vital information related to
the mother and the fetus (foetal heart rate, uterine
contractions, maternal pulse, and blood pressure)
 The partogram should not be commenced
until the latent phase of labour is
complete.
Key Principles for Using the
Partograph
 The partograph is filled out during the labour not
after birth
 During labour, the partograph must be kept in the
labour room
 The partograph is filled in and interpreted by
trained personnel (midwife or obstetrician)
 Filling in the partograph should be stopped when
– Complications requiring urgent delivery arise
 PARTOGRAM
Friedman's partogram - 1954
2 phases of labour (based on dilatation
of the cervix )
Active phase
Latent phase (dilatation < 4 cm)
Active phase (>4 cm dilated)

Latent phase
Philpott and Castle - 1972
Introduced the concept of “ALERT”
and “ACTION” lines.
ALERT LINE – represent the mean rate
of slowest progress of labour

ACTION LINE – appropriate action should

be taken.

Normal labour is plotted to the left alert line

PARTOGRAM
Mother information

Fetal well-being
• Fetal heart rate
• Character of liquor
• Moulding

Labour progress
• Dilatation
• Descent
• Uterine contraction

Medications
• Oxytocin
• Pain relief (e.g. pethidine)

Maternal well-being
• BP, Pulse, Temperature
• Urine – albumin, glucose, acetone
• Urine output
 PARTOGRAM RECORDING
3
Notes should be
legible, dated and
timed.

4
1 Enter the outcome
of delivery
Begin plotting at the
“zero” hour on the
partogram

2
All entries made in
relation to time when the
observations are made
PARTOGRAM

WHAT NEED TO BE
RECORDED
PARTOGRAM RECORDING
Mother information

 Name
 Age
 Parity
 Gestational period
 Date/time of admission
 Time of rupture membrane
 Short antenatal history
PARTOGRAM RECORDING

Fetal information

 Fetal heart rate

 Membrane and amniotic

fluid

 Moulding
PARTOGRAM RECORDING

Fetal information

Fetal heart rate monitoring

1. Safe and reliable way of knowing

fetus is well.

2. Listen after each contraction for one

minutes.

3. Recorded ½ hourly (each square is

½ hour)
PARTOGRAM RECORDING

Fetal information

Character of amniotic fluid

1. State of liquor can assess in

monitoring fetal condition.

2. Observation to be recorded

- Membrane intact record as “I”

- Membrane rupture:
a) liquor clear record as “C”
b) meconiun stained liquor “M”
c) liquor absent record as “A”
PARTOGRAM RECORDING

Fetal information

Moulding of fetal skull

1. Provide information about the

adequacy of pelvis to accommodate
fetal head

2. Record the degree of moulding

0  bones separated
+  bones touching but can
be separated.
++  bone over lapping
+++  bones over lapping
severely
PARTOGRAM RECORDING

Labour Progress

 Cervical dilatation

 Descent

 Uterine contraction
PARTOGRAM RECORDING

Labour progress
Dilatation and Descent

1. Latent (0-4 cm) and Active (4-10

cm) phase.

2. Dilatation of cervix plotted as “X”

axis and Descent plotted as “O”
axis.

3. First vaginal examination done on

admission is recorded.

4. Subsequent vaginal examination is

done every 2-4 hourly.

5. Transfer from latent to active phase.

PARTOGRAM RECORDING
Labour progress recording in
latent phase

Plot dilatation as “X”

Latent phase Plot descent as “O”

At admission:
+
+

- Dilatation  2 cm
- Descent  -2

2 hours after admission:

- Dilatation  2 cm
- Descent  -1

As the dilatation is only 2 cm therefore

the labour progress is in the latent
phase
 PARTOGRAM RECORDING
Labour progress recording in
active phase
Plot dilatation as “X”
Latent phase
Plot descent as “O”
Active phase
+

Latent phase
+

+
+

hours 0 hours 2 hours 4

)admission(
Dilatation
”X “ cm 2 cm 4 cm 7

Descent
”O “ 2- 1- 1+
PARTOGRAM RECORDING

Cervical dilatation

Latent phase
+

If labour progress well plotting of

+

cervical dilatation should always

+

remain to the left of alert line.

If it cross to right of action line this

warns that labour may be prolonged.
PARTOGRAM RECORDING
Labour progress

1. Observation is made ½ hourly

2. Assess the frequency, duration.
3. Each square represent 1 contraction
felt in 10 minutes.
4. Frequency – highlight the numbers
of square.
5. Duration – shade the contraction in
the square.
< 20 sec - Mild

20-40 sec - Moderate

> 40 sec - Strong

PARTOGRAM RECORDING

Labour progress

Recording the uterine on the

partogram

Nos. of
Contraction
in 10 mins

2 weak contractions
in 10 minutes
5 strong contractions
in 10 minutes

3 moderate contractions
in 10 minutes
PARTOGRAM RECORDING

Mother condition

 Vital signs – BP, Pulse, TºC

 Urine analysis – acetone,
albumin, glucose
 Urine volume
 Medications or drug given
PARTOGRAM RECORDING

Mother condition

 Vital signs recording

BP – 4 hourly or more
frequent if indicated
Pulse - ½ hourly

TºC – 4 hourly

 Urine analysis – dipstick

acetone  Nil or +
albumin  Nil or +
glucose  Nil or +

 Urine volume
PARTOGRAM RECORDING
Analyzing the progress of
labour from the partogram
Active phase
If progress is satisfactory the plotting
Latent phase
+
will remain on or to the left of the
+
alert line.
+

+
+

If labour is not progressing normally

the plotting will be to the right of the
alert line.
PARTOGRAM RECORDING

LABOUR PATTERNS

Active phase
Latent phase
Normal labour

Prolonged latent phase

Primary dysfunctional
labour

Secondary arrest
 Abnormal labor
Failure to progress in
labor and its
managemet
Diagnosing When Labour is
Progressing Unsatisfactorily
 False labour
 Prolonged latent phase
 Prolonged active phase
– Cephalopelvic disproportion/Obstructed labour
– Inadequate uterine activity
– Malpresentation or malposition
 The Partograph serves as an “early warning
system” for recognizing the unsatisfactory progress
of labour
False Labour
 Findings
– Cervix not dilated 
– No palpable contractions/infrequent contractions

 Management
 Discharge patient from labor
Prolonged latent phase
Prolonged latent phase occurs when the
latent phase is longer than the arbitrary
time limits discussed previous lecture. It is
more common in primiparous women and
probably results from a delay in the
chemical processes that occur within the
cervix that soften it and allow effacement.
Prolonged latent phase can be extremely
frustrating and tiring for the woman.
However, intervention in the form of
artificial rupture of membranes (ARM) or
oxytocin infusion will increase the
likelihood of poor progress later in the
labour and the need for caesarean birth. It
is best managed away from the labour suite
with simple analgesics, mobilization
and reassurance.
The partogram should not be commenced
until the latent phase of
labour is complete.
Primary dysfunctional labor
Primary arrest’
is the term used to describe poor progress
in the active first
stage of labour (<2 cm cervical
dilatation/4 hours) and is also more
common in
primiparous women. It is most commonly
caused by inefficient uterine
contractions,but can also result from
cephalopelvic disproportion (CPD),
malposition and malpresentation of the
fetus.
 2ndry arrest of labor
‘Secondary arrest’ occurs when
progress in the active first stage is
initially good but then slows or stops
altogether, typically after 7 cm dilatation.
Although inefficient uterine contractions
may be the cause, fetal malposition,
malpresentation and CPD feature more
commonly than in primary arrest.
.
Arrest in the second stage of labour’ (not
to be
confused with ‘secondary arrest’) occurs
when delivery is not imminent after the
usual interval of pushing in the second
stage of labour. This may be due to
inefficient uterine activity, malposition,
malpresentation, CPD or a resistant
perineum. In some cases it may be due to
maternal exhaustion, fear or pain.
Cephalopelvic disproportion (‘passages’
and ‘passenger’)
CPD implies anatomical disproportion
between the fetal head and maternal
pelvis. It can be due to a large head, small
pelvis or a combination of the two
relative to each other. Women of short
stature (<1.60 m) with a large baby in
their
firstpregnancy are potential candidates to
develop this problem. The pelvis may
be unusually small because of previous
fracture or metabolic bone disease.
Rarely, a fetal anomaly will contribute to
CPD. Obstructive hydrocephalus may
cause macrocephaly (abnormally large fetal
head), and fetal thyroid and neck
tumours may cause extension at the fetal
neck.
Relative CPD is more common and
occurs with malposition of the fetal head.
The OP position is associated with
deflexion of the fetal head and presents a
larger skull diameter to the maternal
pelvis .
Oxytocin can be given carefully to a
primigravida with mild to moderate CPD
as long as the CTG is normal. Relative
disproportion
may be overcome if the malposition is
corrected (i.e. rotation to a flexed
OAposition).
 Oxytocin must never be used in a
multiparous woman where CPD is
suspected.
Signs of obstruction
Fetal head is not engaged.
Progress is slow or arrests despite
efficient uterine contractions.
Vaginal examination shows severe
moulding and caput formation.
Head is poorly applied to the cervix.
Haematuria
Malpresentation (the ‘passenger’)

A firm application of the fetal presenting

part on to the cervix is necessary for
good progress in labour. A face
presentation may apply
poorly to the cervix and the resulting
progress in labour may be poor, although
vaginal birth is still possible.
Brow presentation is associated with the
mentovertical
diameter presenting, which is simply too
large to fit through the bony
pelvis unless flexion occurs or there is
hyperextension to a face presentation
Brow presentation therefore often
manifests as poor
progress in the first stage, often in a
multiparous woman. Shoulder presentations
cannot deliver vaginally and once again
poor progress will occur.
Malpresentations are more common in
women of high parity and carry a risk of
uterine rupture if labour is allowed to
continue without progress.