PARTOGRAPH

PRESENTERS: MODERATORS:

Dr Prag GK Subedi Dr Ruby Shrestha( Consultant)

Department Of OBS/GYNAE
Intern, NMCTH, Birgunj
Dr Saruna Pathak( 3rd Year PG)
Dr Ranjan Yadav Department Of OBS/GYNAE
Intern ,NMCTH, Birgunj
DEFINITION:

• Partograph is a composite graphical record of key data (maternal and fetal)

during labor, entered against time on a single sheet of paper.
• It is similar for nulliparous and multiparous.
• It was designed by WHO for use in developing countries.
• Can serve as an “early warning system” and assist in making
decision and interventions.
HISTORY OF PARTOGRAPH:

1ST PARTOGRAPH: FRIEDMAN CURVE:

• Given by friedman in 1954.

• He divided first stage of labour into latent phase and active
phase.
• The pattern of cervical dilatation during the latent and
active phase of normal labour is sigmoid curve.
• Friedman subdivided the active phase into:
i. Acceleration phase : 3-4 cm of cervical dilatation
ii. Phase of maximum slope: 4-9 cm of cervical dilatation
iii. Decceleration phase: 9-10 cm of cervical dilatation
• Friedman’s curve is based on 2 principles:
i. Active phase begins at 3 cm dilatation.
ii. Latent phase was said to be prolonged if it was more or
equal to 8 hrs.
2ND PARTOGRAPH :

• In 1972 Philpott and Castle introduced the concept of "ALERT" and "ACTION'
lines.
• The alert line represented the mean rate of slowest progress of labor(1cm/hr)
for nulliparous women starting at zero time i.e. Time of admission .
• According to them labour is considered progressing normally till it remains left
to left of alert line.
• Action line drawn four hours to the right of the alert line showing 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.
3RD PARTOGRAPH : WHO COMPOSITE
PARTOGRAPH:
• It was introduced in 1994 AD by who as a part of safe
motherhood initiative.
• Its main purpose was to avoid prolonged labour and
intervene timely
• It is based on following 4 principles:
i. Latent phase is said to be prolonged if more or equal to
8 hrs
ii. Active phase begins at 3 cms dilatation.
iii. Mininimum dilatations in active phase should be 1 cm/hr
iv. Time duration between alert line and action line is 4 hrs.
 4 TH PARTOGRAPH: MODIFIED WHO
PARTOGRAPH:
• WHO composite partograph was modified in 2000 A.D.
• The latent phase has been removed to make it simpler and easier to use.
• And plotting in the graph begins in the active phase when the cervix is 4 cm dilated.
OBJECTIVES:

• Early detection of abnormal progress of a labour and prevention of prolonged

labour.
• Recognize cephalopelvic disproportion long before obstructed labour.
• Assist in early decision on transfer , augmentation , or termination of labour.
• Increase the quality and regularity of all observations of mother and fetus.
• Early recognition of maternal or fetal problems.
• The partograph 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.).
PARTOGRAPH FUNCTION:
• The partograph 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 partograph's critical function is to give early warning if
labour is likely to be prolonged and 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
partograph and are essential features in management of labour.
ADVANTAGES OF PARTOGRAPH:

(I) A single sheet of paper can provide details of necessary information at a glance.
(II) No need to record labor events repeatedly.
(III) It can predict deviation from normal progress of labor early. So, appropriate
steps could be taken in time.
(IV) It facilitates handover procedure.
(V) Introduction of partograph in the management of labor (WHO 1994) has
reduced the incidence of prolonged labor and cesarean section rate. There is
improvement in maternal morbidity, perinatal morbidity and mortality.
DISADVANTAGES OF PARTOGRAPH:
• Assumes all women progress at same rate so may
influence the intervention rate.
• Clinical findings have subjective variations.
• lack of knowledge.
• Non availability of printed partographs.
• Duplication of recording.
COMPONENTS OF PARTOGRAPH:

Patient identification.
Date and time.
Part 1: Fetal condition (at the top).
Part 2 : Progress of labour( at the middle).
Part3:Maternal condition (at bottom).
PART1:FETAL CONDITION:
This part of the graph is used to monitor and assess fetal condition.
1- Fetal heart rate.
2 - Membranes and liquor.
3 - Moulding the fetal skull bones.
STATE OF MEMBRANE AND COLOUR OF LIQOUR:
• To mark ‘I’ for Intact membranes=I
• Ruptured membrane + clear liquor=C
• ‘Ruptured membrane + meconium stained liquor=M
• Ruptured membrane + blood stained liquor=B
• Ruptured membrane + absent liquor = A
FETAL HEART RATE:
• Baseline heart rate is best determined over 2-5 min.
• Normal :110-160 beats/min.
• Recorded at every 30 minutes.
MOULDING OF 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.
• Grading of moulding:
i. Separated bones (sutures felt easily) = 0
ii. Bones just touching each other = +
iii. Overlapping bones ( reducible) = ++
iv. Severely overlapping bones ( non - reducible) = +++
PART 2: PROGRESS OF LABOUR

• Cervical dilatation (X)

• Descent of the fetal head (O)
• Uterine contractions.
PHASE OF LABOUR:

• Latent phase:
– It starts from onset of labour until the cervix reaches 4 cm dilatation ,
– Once 4 cm dilatation is reached , labour enters the active phase.
– Its not mentioned in modified WHO partograph.

• Active phase :
– Contractions at least 3 / 10 min.
– Each lasting > 40 seconds.
– The cervix should dilate at a rate of 1 cm / hour or faster.
ALERT LINE ( HEALTH FACILITY LINE ):
• The alert line drawn from 4 cm dilatation represents the rate of dilatation of 1cm /
hour.
• Moving to the right of the alert line means referral to hospital for extra vigilance.
ACTION LINE (HOSPITAL LINE ):
• The action line is drawn 4 hour to the right of the alert line and parallel to it.
• This is the critical decisions must be line at which specific management made at the
hospital.
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 the left of it.
• If a woman arrives in the active phase of labour , recording of cervical dilatation
starts on the alert line.
DESCENT OF 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 felt by abdominal
examination to be above the level of symphysis pubis.
• When 3/5 or less of fetal head is felt above the level of symphysis pubis , this
means that the head is engaged ,
• And by vaginal examination , the lowest part of vertex has passed or is at the
level of ischial spines.
 UTERINE CONTRACTIONS:
• Observations of the contractions are made every half-hour in the active phase .
• Assessed by number of contractions in a 10 minutes period of duration
• Measured in seconds from the time the contraction is first felt abdominally , to
the time the contraction phases off.
• Each small square represents one contraction.
• Adequate uterine contractions refers to 3 contractions in 10 mins each lasting
for 45 secs and causing intrauterine pressure of 65-75 mm of Hg or 220
montivideo units
• Tachysystole is defined as more than 5 contractions in 10 mins ( averaged over
30 mins)
• Term tachysystole can be applied to spontaneous or induced labor. When
tachysystole causes fetal distress it is called hyperstimulation.
METHODS OF ASSESMENT OF UTERINE
CONTRACTIONS:

• Manual assessment: This method measure the frequency and duration of

contractions. Contractions are predominant over fundus.
• Cardiotocography: This method also measure the frequency and duration of
contractions.
• Intrauterine pressure catheters (IUPC) to measure intrauterine pressure in
Montevideo units OR mm of Hg: This method will measure the intensity in addition
to frequency and duration.
• NOTE: 1 montivideo units = No of contractions in 10 min x Intensity of contraction
in mm of Hg.
EVENTS INTRAUTERINE PRESSURE
Contractions are palpable 10 mm of Hg
Contractions are painful 15 mm of Hg
Cervix dilates 15 mm of Hg
Fundus cant be indented 40 mm of Hg
1st stage of labor 40 to 50 mm of Hg
2nd and 3rd stage 100 to 120 mm of hg
PART 3: MATERNAL CONDITION:
Assess maternal condition regularly by monitoring :
• Drugs , IV fluids , and oxytocin , if labour is augmented.
• Pulse , blood pressure , temperature.
• Urine volume, colour, analysis for protein and acetone.
• Drugs : As given.
• Fluids: Type and amount used.
• Maternal pulse: Recorded every half an hourly (marked with dot).
• Blood pressure : Every 4 hourly (in vertical line)(marked with arrows)
[ Measured hourly if patient is case of pregnancy induced HTN]
• Oxytocin concentration (U/L) in upper box.
• Oxytocin doses (drops/min) in lower box.
• Urine evaluation: For acetone, protein (every time urine is passed),
volume,colour.
• Temperature record: Every 4 hourly.
MANAGEMENT OF LABOUR USING PARTOGRAPH:
• Progress in active phase remain on left of the alert line.
• Do not augment with oxytocin if latent and active phases go normally.
• No ARM to be done in latent phase.
• ARM can be done at any time in the active phase.
BETWEEN ALERT AND ACTION LINE:

• In PHCs, Health posts : 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.
BEYOND ACTION LINE:

• Conduct full medical assessment.

• Consider intravenous infusion / bladder catheterization / analgesia.
• Options:
Deliver by cesarean section if there is fetal distress or obstructed labour.
Augment with oxytocin by intravenous infusion if there are no contraindications.
ABNORMAL PROGRESS OF LABOUR:

One of the main function of the partograph is to detect early deviation from
normal progress of labor.
MOVING TO THE RIGHT OF ALERT LINE:
• This means warning.
• Transfer the woman from health center to hospital.
• Reaching the action line this means possible danger.
• Decision needed on future management (usually by obstetrician or resident ).
PROLONGED LATENT PHASE:
• Average duration of latent phase in nulliparous and multiparous women is 12 hrs and
8hrs respectively.
• It is prolonged when its duration exceeds 20 hours in nulliparous and 14 hours in
multiparous.
• According to who partograph, a prolonged latent phase is “cervix is not dilated
beyond 4 cm even after 8 hours ”.
• Causes of prolonged latent phase of labor:
i. Excessive sedation or epidural analgesia.
ii. Poor cervical condition( eg. Thick, uneffaced, or undilated) i.e unripened cervix.
iii. False labor pain.
iv. Poor contractions.
PROLONGED LATENT PHASE MANAGEMENT:

• Reassurance.
• Therapeutic rest ( 15 mg morphine is given im. Most of the patients are asleep
within 1 hour and awake after 4 to 5 hours later in active labor or in no labor)
• Simple analgesics.
• Mobilisation .
• Active management in the form of augmentation of labor or CS may be done if
its indicated.
 ABNORMALITIES OF ACTIVE PHASE:
• PROTRACTED ACTIVE PHASE: Normally in active
phase 2 things happen i.e. Dilatation of cervix and
Descent of fetal head
i. Dilatation of cervix
In nulliparous: 1.2 cm/hr
In multiparous: 1.5 cm/hr
ii. Descent of fetal head:
In nulliparous: 1 cm/hr
In multiparous: 2 cm/hr
- According to WHO minimum dilatation should be 1 cm/hr.
- If rate of dilatation and descent of fetal head is slower than
above mentioned values then it is protracted active phase.
- MANAGEMENT OF PROTRACTED ACTIVE PHASE:
i. Rule out CPD ( If CPD go for CS).
ii. Rule out Occipitoposterior position ( If present
management is wait and watch ).
iii. After ruling out above 2 and if they are not the cause for
protraction then accelerate/augment labor by artificial
rupture of membranes (ARM and oxytocin infusion.
• ACTIVE PHASE ARREST :
- In case of spontaneous labor; when there is >= 6 cm dilatation of
cervix with ruptured membranes and yet no change in dilatation and one of
the following:
i. 4 or more hours of adequate contractions OR
ii. 6 hours or more of inadequate contractions with oxytocin
infusion.
- 2 pre-requisite to make diagnosis of active phase arrest are:
i. Uterine contractions should be adequate.
ii. Membranes should be ruptured.
- MANAGEMENT: Go for CS
ABNORMALITIES OF SECOND STAGE OF LABOR:
• AVERAGE DURATION OF 2ND STAGE:
Nulliparous: 1 hr ( + 1 hr if epidural given)[ i.e 1cm/hr descent]
Multiparous: 30 min ( + 1 hr if epidural given ) [i.e 2cm/hr
descent]
• PROLONGED SECOND STAGE/ PROTRACTED DESCENT:
Nulliparous : 2 hrs of no change or progress in descent( +1 hr in
case of epidural ) [i.e less than 1 cm/hr]
Multiparous: 1 hr of no change or progress in descent( + 1 hr in
case of epidural ) [i.e less than 2cm/hr ]
- MANAGEMENT OF PROLONGED SECOND STAGE:
Depends on station of fetal head ;
If at +2 station: Apply forceps/ vaccum.
If less than +2 station i.e above + 2: Go for CS.
• SECOND STAGE ARREST:
In nulliparous: 3 hrs of no change or progress in descent.
(+1 hr if epidural given ).
In multiparous: 2 hrs of no change or progress in
descent( + 1 hr if epidural given ).
- MANAGEMENT : Go for CS.
 PARTOGRAPH CONCLUSION:

• Partograph is a simple, clear, easy to use, cost effective tool for monitoring of labor
and decisions making.
• The use of the partograph significantly improves perinatal outcomes.
• The partograph can be effectively used in facilitates at any level of care.
• Strictly following the rules for partograph use ensure its effectiveness.
• The partograph should be used for any labor, in high and low risk women.
• Documented evidence for medico legal purpose.
• Educational value for all grades of staff.
REFERENCES:
• DC Dutta’s Textbook Of Obstetrics, 9 th edition
• William’s Textbook Of Obstetrics, 25th edition
• The Partograph (WHO)
THANK YOU!!!