PARTOGRAPH
DR KALYANI MAHAJAN
ASSOCIATE PROFESSOR
DEPARTMENT OF OBSTETRICS & GYNAECOLOGY
SMCW & SUHRC
Partograph is a composite graphical record of key
data (maternal and fetal) during labor, entered
against time on a single sheet of paper.
The partograph or partogram has been established as the “gold standard” labor
monitoring tool universally.
It has recommended by the World Health Organization (WHO) for use in active
labor.
The function of the partograph is to monitor the progress of labor and identify
and intervene in cases of abnormal labor.
The partograph is an “easy-to-use” tool, but if not used correctly it will affect
the final outcome.
HISTORY AND EVOLUTION OF
PARTOGRAPH
Most guidelines for normal human labor progress are derived from
Friedman’s clinical observations of women in labor.
In 1954, he introduced the concept of partogram by graphically plotting
cervical dilatation against time.
The curve obtained was a sigmoid curve. He divided the first stage of labor
into latent phase and active phase.
Active phase was further divided into acceleration, maximum slope and
deceleration.
Friedman’s Partograph 1954
Philpott & Caste — 1972 partograph is an improved version
of the labor curve.
He introduced the alert line and action line.
Alert line: represents the mean slowest rate of progression of
labor (1 cm/hr) started at 0 time
Action line: it is drawn 4 hours to right of the alert line and
parallel to it. It represents the time after which action is to be
taken.
In 1987, WHO launched the safe motherhood initiative.
The first of these partograms also known as composite partograph
includes latent phase of 8 h and an active phase starting at 3-cm
cervical dilatation.
It has an alert line with a slope at 1 cm/h and the action line 4 h to
the right and parallel to alert line.
It also provides space for recording descent of fetal head, maternal
condition, fetal condition and medicines administered
WHO modified the partograph in 2000, the latent phase was
excluded, and the active phase commenced at 4-cm cervical
dilatation.
The reason for excluding the latent phase was more likelihood
of interventions due to prolonged latent phase which was
overdiagnosed.
WHO further modified the partograph for the third time.
This simplified partograph is color-coded.
The area to the left of the alert line is colored green representing the
normal progress.
The area to the right of action line is colored red indicating
dangerously slow progress.
The area between the alert and action line is
colored amber indicating the need for greater vigilance.
Simplified partogram is more user-friendly over composite
partogram
Components of partograph
1. The fetal condition is monitored by fetal heart rate, color of amniotic
fluid and molding of the fetal skull
2. The progress of labor is monitored by cervical dilatation, descent of
head and uterine contractions
3. Maternal condition is assessed by pulse, BP, temperature, urine output
and urine for protein and acetone
4. A separate space is given to enter drugs, IV fluids and oxytocin.
The Fetal Condition
Fetal Heart Rate
Immediately below the patient’s identification details, there is
fetal heart rate record. The scale for fetal heart rate ranges
from 100 to 180 beats/min.
Liquor
Below the fetal heart rate, there are two rows, and the first is for liquor. Once the
membranes rupture, the color of amniotic fluid is noted
1. If the membranes are intact, write ‘I’
2. If the liquor is clear, write ‘C’
3. If the liquor is meconium-stained, write ‘M’
4. If the liquor is absent, write ‘A’
Molding
The row below the liquor is assigned for molding. Increasing molding
with high head in pelvis is an ominous sign. It is recorded as follows.
Grade-1 (0) Bones are separated, and the sutures can be felt easily.
+ Bones are just touching each other but not overlapping
++ Bones are overlapping but easily separated
+++ Bones are overlapping severely/ fixed overlapping
Progress of Labor
Cervical Dilatation : Along the left side, there are squares from 0 to 10, each
representing 1-cm dilatation. Along the bottom of graph are lines
representing 1 h.
The active phase is from 4 to 10 cm (full cervical dilatation).
The dilatation of cervix is plotted with “x.”
When a woman is admitted in the active phase, the cervical dilatation is
plotted on the alert line.
Descent of Fetal Head
Descent of the head should always be assessed by abdominal
examination.
The level of the fetal head by abdominal palpitation is
expressed in terms of fifths above the brims.
On the left side of the graph is the word descent with
numbers from 5 to 0. Descent is plotted with “O” on
cervicograph.
Uterine Contractions
Below the cervical dilatation, there is a space for recording
uterine contractions per 10 min and the scale is numbered
from 1 to 5.
Each square represents one contraction.
So if two contractions are felt in 10 min, two squares are
shaded. Duration of contraction is indicated by the following
symbols.
Maternal Condition
All the recordings for the maternal condition are entered at
the foot of the partograph.
Maternal vital signs such as temperature, pulse, BP, urine
output and urine for protein and acetone are monitored.
The components of a partograph
are:
Patient identification;
(a)
(b) Time — recorded at hourly interval. Zero time for spontaneous labor
is the time of admission in the labor ward.
(c) Fetal heart rate — recorded at every 30 minutes
(d) State of membranes and color of liquor
(e) Cervical dilatation and descent of the head
(f) Uterine contractions
(g) Drugs and fluids
(h) Oxytocin — concentration in the upper box and dose (m IU/min) in
the lower box;
(i) Urine analysis
(j) Blood pressure (recorded in vertical line) at every 2 hours and pulse
at every 30 minutes;
(k) Temperature record.
Advantages of a 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.
THANK YOU
