PARTOGRAPH
Introduction
Partograph is the most important tool for health workers at any level to assess the progress of
labour and take appropriate actions. It is a graphic recording of the progress of labour and
condition of mother and fetus.
Definition
Partograph is a graphical information about tge progress of labour in which the salient
information about i) the fetal wellbeing ii) Maternal well-being, iii) the progress of labour is
recorded into a chart.
Purpose
a) Early detection of abnormal progress of labour
b) Increase the quality and regularity of all observations of mothers and fetus.
c) Prevention of prolonged labor
d) To provide a basis of decision making
e) To facilitate research
f) To defend one’s actions- no documentation- nondefense.
Importance of using partograph
a) It allows an instant visual assessment of the rate of cervical dilation and comparison with
an expected normal, so that abnormal progress can be recognized.
b) Early and appropriate actions taken to correct it where possible.
c) To initiate appropriate interventions- it to prevent prolonged and obstructed
Who require partograph recording
For all women who are in labour that is either low or high-risk group.
Who can plot partograph
A trained healthcare professional, typically a midwife or obstetrician, can plot a partograph.
Principles to plot partograph
a) Active phase is commenced at 4cm dilation.
b) Latent phase should not last longer than 8 hours
c) During active labour, the rate of cervical dilation should be not be slower than 1cm per
hour.
d) Per vaginal examination should be performed as in frequently as it is compatible with safe
practice (4 hourly recommended)
components of the partograph
1. Mother’s information
2. Fetal information
Fetal heart rate
Amniotic fluid and moulding
3. Labour progress
Dilatation of cervix
Descent of head
Uterine contraction
Hour and time
4. Medications
Oxytocin
Drugs and fluids
5. Maternal well being
BP, Pulse, Temperature
Urine-albumin, acetone, glucose
MOTHERS INFORMATION
It includes name, age, parity, hospital bed number, date & time of admission and the time at
which membranes ruptured.
FETAL INFORMATION
Fetal heart rate
Membrane and amniotic fluid
Moulding
Fetal heart rate
Fetal heart rate should be noted every half hour in the first stage and every 15 minutes in the
second stage or following the rupture of the membrane.
Normal FHR = 120 -160 bpm
marked tachycardia - >180bpm
moderate tachycardia – 160 – 180 bpm
moderate bradycardia -100 – 120 bpm
marked bradycardia - < 100 bpm.
Amniotic fluid and moulding
Amniotic fluid- The colour of the amniotic fluid should be recovered at every vaginal
examination. The marking criteria are as follows:
Membrane intact =1
Membrane ruptured,
clear fluid = C
Meconium stained = M
Blood stained fluid =B .
Liquor absent =A
Moulding- Overlapping of cranial bones or shaping of the fetal head to accommodate &
conform to the bony and soft parts of the mother’s birth canal during labour.
The marking criteria are:
Bones separated = 0
Sutures apposed = 1+
Sutures overlapped but reducible = 2+
sutures overlapped & reducible = 3+
LABOUR PROGRESS
Latent phase
It starts from onset of labor until the cervix reaches 4 cm dilatation
It lasts eight hours or less
Contractions occur at least twice every 10 minutes with each lasting >20 seconds
Active phase
It starts when the cervix reached 4 cm dilatation.
Contractions occur three times every 10 minutes with each lasting > 40 seconds.
The cervix should dilate at a rate of 1cm/hour or faster.
Why latent phase is removed
In modified partograph the latent phase is removed.
Having a arbitrary time limit for latent phase of 8 hour increases the risk of incorrect
diagnosis of labor and could thus increase the risk of non-indicated interventions and
morbidity
On the other hand the risk of “prolonged latent phase” in the presence of intact membranes
and no other complications is almost minimal.
Lastly, the transfer from latent phase to active phase by health workers was reportedly a
major source of confusion and error in partograph.
Dilation of Cervix
This is the graphical representation of cervical dilation .
The latent phase has been removed & plotting on the cervicograph begins in the active phase
when the cervix is 4 cm dilated. Cervical dilation rate is divided into two alert line and action line.
Alert line starts at the beginning of the active phase i,e 4cm cervical dilation and ends with full
dilation of the cervix is 10 cm in 6 hours (1 cm per hour dilation rate)
Action line is drawn four hours to the right of the alert line, parallel to it.
In a normal labour, the cervicograph should be either on the alert line to the left of it . When the
cervicograph crosses the alert line and falls on zone 2, it needs to be critically assessed. When the
cervicograph crosses the action line & falls on zone 3, it should be reassessed by a senior person
and intervention is required. Decision is to be made either termination of labour or for
augmentation of labour.
Descent Of The Head
It refers to the part of the head divided into five parts palpable above the symphysis pubis. It is
recorded as a circle (0) at every abdominal examination.
The marking criteria are:
sinciput = 5/5
sinciput prominent & occiput ascending = 4/5
sinciput rising & occiput can be tipped = 3/5
sinciput not so prominent = 2/5
sinciput & occiput not felt =1/5
head on pelvic floor = 0/5
Uterine Contraction
Uterine contraction should be monitored every 15 – 30 minutes during the phase of labour.
Charting of the uterine contraction should be done every half an hour, palpating the number of
contraction in 10 minutes.
Frequency
How often are they felt?
Frequency of contractions is assessed by the number of contractions in a 10minute 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.
The charting pattern is as follows
Hour and time
Hours- refers to the time elapsed since onset of active labour.
Time- record actual time according to the hours of active phase of labour started.
The time is recorded hourly intervals in the space provided. “0” hour time for spontaneous
labour is the time of admission to the labour Ward and for induced labour is the time of induction.
Then time is recorded on the basis of first vaginal examination.
Medications
Oxytocin- record the amount of oxytocin per volume and intravenous fluid in drops per
minute in every 30 minutes when used (on the base of escalating).
Drugs given- any drug given is recorded in the appropriate boxes.
MATERNAL WELLBEING
VITAL SIGNS
BLOOD PRESSURE – The BP is monitored every 30 minutes during the active phase of labour
and it should be marked with arrows. During the period of uterine contraction, the BP will be
raised by 10 mm. Hypotension may be caused by the supine position shock.
TEMPERATURE – The temperature should be recorder every 4 hours during active phase of
labour. The normal temperature is 98.6 degree farenheit. It is very essential to know the signs of
infection and fluid deficit of a mother.
PULSE – A steady pulse rate is an indication of good maternal condition. If the rate increases to
more than 100 beats per minute, it may be indicative of infection, ketosis or haemorrhage.
URINE – A clean catch urine specimen may be obtained to gather further data about the pregnant
women’s health. The presence of protein, acetone, and the volume of urine should be recorded
every time urine is passed.
Recommendations for taking action
If progress is satisfactory the plotting 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.
Left of or on the alert line
Do not augment with oxytocin or intervene unless complications develop.
ARM may be done at anytime in the active phase (No ARM in latent phase)
Between alert and action lines
Common causes: Inefficient uterine contraction or cephalopelvic disproportion.
Must exclude CPD: must experience.
Perform ARM if membranes are intact
Continue routine observations
Supportive therapy (only if satisfactory progress is now established and dilatation could be
anticipated at 1cm/hour or factor
At or beyond active phase action line
Full medical assessment
Consider IV in infusion/ bladder catheterization/ analgesia
Delivery by c-section if fetal distress or obstructed labour
Oxytocin augmentation if no contraindication.
Do AROM before giving uterotonic agents. If uterotonic agents given agents before
AROM
If fetal heart rate change
Immediately administer oxygen and reduce oxytocin/stop oxytocin, reposition the
mother and prepare further interventions such as assisted delivery or emergency
caesarean section if necessary.
ADVANTAGE
A single sheet of paper can provide details of necessary information at a glance.
It is easier to keep, rather than making detailed notes at intervals.
It facilitates handover procedures
It serves as an early warning in case of impending problems.
Record are straight forward & objectives, both nursing & medical staff can see the
progress of labour at a glance
Disadvantages
Dependency on accurate data entry
Inability to predict all labour complications
Variations in interpretation among health care providers
Insufficient evidence of effectiveness in reducing adverse outcomes
Resource and training requirements for implementation
