The Partograph

The Partograph
I. The Partograph
A
tool to help in management of labor

birth attendant to identify women whose labor is delayed and therefore decide appropriate action
Guides
OBJECTIVES
I.
To understand the concept of the WHO partograph

To explain to mothers the significance of the graph
II. To record the observations accurately on the graph III. To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral
Monitor during labor

Progress
of labor
Cervical dilatation Contraction pattern

Maternal
well being
Pulse, temperature, blood pressure Urine voided

Fetal
well being
Fetal heart rate and pattern Color of amniotic fluid
The parts of the partograph
Progress of labor
Maternal and fetal well-being
D I L A T A T I O N
Alert line
D I L A T A T I O N
Alert line
Action line
Parallel and 4 hours to the right of alert line
Conditions that do not need the use of partograph

Antepartum
hemorrhage Severe pre-eclampsia and eclampsia Fetal distress Previous cesarean section
Multiple
pregnancy Malpresentation Very premature baby Obvious obstructed labor
II. Recording the findings in the partograph

Start
by labeling the record with pertinent patient identifying information.
Plotting the progress of labor

Plot
only the CERVICAL DILATATION using the symbol X Start when woman is in ACTIVE LABOR (4 cm or more) and is contracting adequately (3-4 contractions in 10 minutes)
Start plotting on alert line in the intersection corresponding cervical dilatation finding
4pm
Indicate the time the IE was made (and therefore, the observation was plotted)
Write this in the vertical line itself where you plot the X, NOT the space after it
X X
4pm
8pm
10pm
Perform internal examination every 4 hours, or more often if necessary, and plot findings each time
Also, do not forget to write the time each observation was made
X X
4pm
8pm
10pm
Connect the Xs to demonstrate the pattern of labor
EXAMPLE
x
1am
A G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix.
EXAMPLE
x
x
1am 5am
At 5 am, another IE showed 9 cm dilated cervix.
EXAMPLE
x x
x
1am 5am 7am
At 7 am, the patient is 10 cm dilated, intact BOW.
III. Distinguishing normal from abnormal labor pattern
X X X
4pm
6pm
8pm
10pm
Progress of labor is normal if plotting stays on or to the left of the alert line (green part)
4cm = active labor

4pm
6pm
8pm
10pm
Note that based on the structure of the partograph as soon as 4 cm is reached the cervix should dilate normally at a rate of 1 cm/hour.
X X
4pm
6pm
8pm
10pm
12am
2am
Plotting that passes the alert line (yellow part) more so if it reaches or passes the action line (red part) indicates abnormal progress of labor
If plotting passes alert line

Reassess
woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminent Alert transport services Monitor intensively
If plotting reaches the action line
the patient must be already in an EmOC facility, a decision made about the cause of slow progress, and appropriate action taken
Progress of labor
Maternal and fetal well-being
IV. Other findings to note (and record) during IE

Status If
of membranes, write
I if intact
ruptured, note color of amniotic fluid, write

C if clear M if meconium stained A if absent B if bloody
Monitor every 4 hours* and record the findings

Blood
Pressure Pulse rate Temperature Urine voided (yes or no)

* More frequently, if indicated
Monitor more frequently and record the findings

Number
of contractions in 10 minute period Fetal heart rate in 1 full minute
If
woman is admitted in LATENT PHASE of labor (less than 4 cm dilated) record only other findings (BP, FHT etc). she remains in latent phase for next 8 hours (labor is prolonged), transfer her to hospital.
If
EXERCISES
Indicate
whether the progress of labor in the following partographs are normal or abnormal.
Case 1
x
10pm 2am
Case 2
X X
8pm
12mn
2am
4am
Case 3
X X
9pm
1am
3am
EXERCISES
Plot
the observations in the following cases.
Case 4:
Maria, G2P1 was admitted today at 2 am, IE showed a 5cm dilated cervix, cephalic, intact BOW. BP=110/70, PR=88/min, afebrile. FHT=140/min. She had moderate contractions (3 in 10 min). At 6 am, the BOW ruptured with clear amniotic fluid. IE showed 8 cm dilated cervix. Vital signs were the same. At 8 am, cervix was 9 cm. She delivered spontaneously at 8:30 am. 10 u oxytocin was given IM. Placenta was delivered complete at 8:35 am.
Maria, G1P0 Date Today

X
2am
X X X
6am
0
C
8am
0 I 140 88
110/70
140 88
110/70
8:35
8:30
Case 5:
Lourdes, G4P2 was admitted at 1 pm today due to watery vaginal discharge. The cervix was 3 cm, cephalic, intact BOW. BP=120/80, PR=80/min, T-36.5. At 5pm, contractions were moderate, 3 in 10 min. IE showed cervix 4 cm dilated. Vital signs remained the same. At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, meconium stained fluid. BP-110/70, PR92/min, T-37.5, FHT-140/min
Lourdes, G4P2 Date Today

X
5pm
9pm
1am
0
3
80 120/80
3 36.5 120/80
80
M 37.5
36.5
92 110/70
Case 6:
Marites, G1P0 was admitted at 6 pm. BP=120/80, PR-84/min, T=36.5. FHT=150/min, cervix 5 cm dilated, (+) BOW. She had 2-3 uterine contractions in 10 min. After 4 hours, IE showed 7 cm dilated cervix. Vital signs and FHT were the same. At 12 am, another IE done showed 8 cm dilated cervix, negative BOW, clear AF. FHT= 140/min. Another IE after 2 hours was the same. FHT=144/min, Vital signs same
Marites, G1P0 Date Today

X
6pm
10pm
12am
2am
2
I 2-3 140 36.5 84 120/80 5
I 3 140 36.5 84 120/80 7
C 140
C 144 36.5 120/80 8
RECAP
Significance
and use of the partograph Parts of the partograph and information contained in it Recording or plotting of clinical observations Interpretation of the recorded findings and decision on referral

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The Partograph

tool to help in management of labor

To understand the concept of the WHO partograph

Monitor during labor

Cervical dilatation Contraction pattern

Pulse, temperature, blood pressure Urine voided

Fetal heart rate and pattern Color of amniotic fluid

The parts of the partograph

Maternal and fetal well-being

Parallel and 4 hours to the right of alert line

Conditions that do not need the use of partograph

pregnancy Malpresentation Very premature baby Obvious obstructed labor

II. Recording the findings in the partograph

by labeling the record with pertinent patient identifying information.

Plotting the progress of labor

Connect the Xs to demonstrate the pattern of labor

A G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix.

At 5 am, another IE showed 9 cm dilated cervix.

At 7 am, the patient is 10 cm dilated, intact BOW.

III. Distinguishing normal from abnormal labor pattern

4cm = active labor

If plotting passes alert line

If plotting reaches the action line

Maternal and fetal well-being

IV. Other findings to note (and record) during IE

ruptured, note color of amniotic fluid, write

Monitor every 4 hours* and record the findings

Pressure Pulse rate Temperature Urine voided (yes or no)

Monitor more frequently and record the findings

of contractions in 10 minute period Fetal heart rate in 1 full minute

the observations in the following cases.

Maria, G1P0 Date Today

Lourdes, G4P2 Date Today

Marites, G1P0 Date Today

I 2-3 140 36.5 84 120/80 5

I 3 140 36.5 84 120/80 7

C 144 36.5 120/80 8

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