PARTOGRAPH

Learning Objectives:
At the end of this module, the student should be able to:
1. Understand the concept of the WHO partograph
2. Describe the proper use of partograph including maternal and fetal signs.
3. Interpret the recorded findings, recognize deviation from the norm, and decide on
timely referral.

Introduction:
The Partograph is graphical representation of events, through which maternal or
fetal condition is assessed simultaneously in a single sheet. It is a tool to help in
management of labor. It guides attendant to identify women whose labor is delayed
and therefore decide the appropriate action.

The partograph is probably the simplest and yet the most effective aid to logical
management of labor that has ever been devised. The underlying principles of the
partograph are that:

 It is a method of displaying progress in cervical dilatation as a continuous graph,

while at the same time;
 Displaying as many other features of the state of the mother, the fetus and the
labor as possible in graphic form.

It is this combination of features, which makes the partograph so valuable. This value is
apparent for all health workers from the least to the most experienced, and for all health
care environments from the least to the most sophisticated.

Significance

1. Ensures close monitoring (regular) of the woman in labor and the fetus
2. Aids in the early recognition of problems in the mother in labor (abnormal
progress or prolonged labor) and the fetus, and guides in early decision
making on interventions during labor (transfer, augmentation, or

termination of labor)
3. Helps avoid unnecessary interventions so that maternal and neonatal
morbidity are needlessly increased
4. 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.).

Items recorded on the partograph

The following details are recorded on a partograph:
 The patient:
 o name
o obstetric details (parity, gravidity)
o date of admission
o time of admission
o time of ruptured membranes.

 The fetus:
o –  heart rate
o –  liquor: clear (C), blood-stained (B), meconium-stained (M) or intact (I)
o –  cervix: dilatation in cms, plotted with an X
o –  descent: of the leading surface of the fetal head, expressed in fifths
palpable per abdomen, plotted with an O and established by abdominal
palpation, performed at each and every vaginal examination.
 contractions:
o –  frequency (expressed as number of contractions in 10 minutes)
o –  strength (expressed by intensity of shading).
 oxytocin:

o dosage can be recorded for each hourly period.

o · drugs and intravenous fluids: – free space for details.

 blood pressure, pulse and temperature:

o –  blood pressure and pulse – hourly or more frequently recommended
o –  temperature – 3–4 hourly recommended.
 urine:
o –  quantity
o –  analysis (blood, protein and acetone)
o –  recorded after each time urine is passed.

Components of the partograph

Part 1 : fetal condition ( at top )
• Basal fetal heart rate?
• < 160 beats/mi =tachycardia
• > 120 beats/min = bradycardia
• >100 beats/min = severe bradycardia

Part 11 : progress of labor ( at middle )

• Cervical dilatation
• Descent of the fetal head
• Fetal position
• Uterine contractions
• this section of the paragraph has as its central feature a graph of
cervical dilatation against time
• it is divided into a latent phase and an active phase
Cervical dilatation
• most important information and the surest way to assess progress of labor
• when progress of labor is normal and satisfactory , plotting of cervical
dilatation remains on the alert line or to left of it
• if a woman arrives in the active phase of labor , recording of cervical
dilatation starts on the alert line
• when the active phase of labor begins, all recordings are transferred and
start by plotting cervical dilatation on the alert line
• Begin partograph at 4cm
• Mark with an x

Descent of the fetal head

• 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 are felt by
abdominal examination to be above the level of symphysis pubis
• When 2/5 or less of fetal head is felt above the level of symphysis pubis, this
means that the head is engage, and by vaginal examination, the lowest part of
vertex has passed or is at the level of ischial spines
Assessing descent of the fetal head by vaginal examination;
0 station is at the level of the ischial spine (Sp). 
Uterine Contraction
• Observations of the contractions are made every hour in the latent phase and
every half-hour in the active phase
• frequency how often are they felt ?
• Assessed by number of contractions in a 10 minutes 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
• Each square represents one contraction

Part 111 : maternal condition (at bottom)

o Name / DOB /Gestation
o Medical / Obstetrical issues
o Assess maternal condition regularly by monitoring :
• drugs , IV fluids, and oxytocin, if labor is augmented
• pulse, blood pressure
• Temperature
• Urine volume, analysis for protein and acetone

Uses of the partograph

• Assessment of progress of labor
▫ Cervical dilatation
▫ Contractions
▫ Alert and action lines
• Assessment of maternal well being
▫ Pulse, temperature, blood pressure
▫ Urine voided
• Assessment of fetal well being
▫ Fetal heart rate and pattern
▫ Color of amniotic fluid
 

 Simplified WHO partograph (2003) 2 parts: cervical dilatation graph and

maternal and fetal well-being monitoring
 Color-coded
 No fetal head descent monitoring
 Incorporated for use in BEmONC facility

Why the partograph?

The delivery of a healthy baby and maintenance of a safe delivery for the mother are two
goals of all maternity health care providers. A simple tool called partograph has been
shown to reduce prolonged labor, the need for augmentation, emergency cesarean section
and intrapartum stillbirths. The partograph should be used in all labor wards and centers
for maternity care.

When should one use the partograph?

A partograph should be started on women who have no complications that require

immediate action, to clearly assess the progress of labor by cervical dilatation. The
pattern of cervical dilatation can be helpful in determining abnormal labor patterns. A
partograph is only started in the active phase when the cervix is at least 4cm dilated. The
dilatation is marked with an X on the alert line and the corresponding time in the
appropriate case or box. The first recording of cervical dilatation in active labor is plotted
on the appropriate position on the Alert line. Ideally labor should then proceed along the
Alert line. If labor is progressing more slowly than this the plot of dilatation against time
will tend to move toward the Action line. The Action line on the WHO partograph is four
hours to the right of the Alert line. Once the plot has crossed the Action line it becomes
appropriate to consider action.
What does the partograph involve?

The partograph requires the assessment of several observations. The first set of
observations relates to progress of labor: cervical dilatation, decent of the fetal head, and
uterine contractions. The second set of observations focuses on the fetus: fetal heart rate,
membranes and molding of the fetal head.

Descent may be assessed abdominally in fifths above the pelvic brim. An abdominal
examination should be done before pelvic assessment. Contractions are observed for
frequency and duration.

Actions taken based on the partograph

The alert line

A laboring mother should be referred from a health center to a hospital when the
cervical dilatation moves to the RIGHT or ALERT LINE. Amniotomy may be
performed if the membranes are still intact, and she may be observed for a short
time prior to considering transfer. In hospital, movement to the RIGHT of the
ALERT line should signal the need for an amniotomy and close observation.

The action line

If the woman’s partograph crosses the ACTION line in a central hospital, active
intervention is required. Initially this would include rehydration, possibly including
oral rehydration, the start of an intravenous line, encouraging the woman to empty
her bladder of bladder catheterization, providing analgesia and augmentation of
contractions using oxytocin. These measures would be carried out as long as there
was no evidence of fetal distress or obstructed labor.

A vaginal examination should be carried out in 3 hours then in 2 hours. The

dilatation rate should be 1cm/hour minimum. Check the fetal heart rate every half-
hour at minimum when oxytocin is being infused. If these measures were not
successful, a cesarean section would be carried out.

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
labor 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 labor are also recorded on the
partograph and are essential features in management of labor
Labor time frames
The mean and least normal rates of progress were historically established by
Friedman in the early 1950’s based on a mixed population of women, including
women in spontaneous labor, women induced with oxytocin and women with
babies presenting in the breech presentation.

Labor pattern Diagnostic criteria

Nullipara Multipara

Latent Phase < 20 h < 14 h

Cervical Dilatation > 1.2 cm/hr > 1.5 cm/hr

Fetal Descent > 1 cm/hr > 2 cm/hr

Monitoring the progress of labor with partograph

Latent and active phase of labor
o The first stage of labor is divided into the LATENT and ACTIVE phase
▫ Latent Phase: corresponds to the preparatory division
▫ Ends between 3-5 cm of dilatation
▫ Factors that affect duration: excessive sedation, epidural analgesia,
unfavorable cervix, and false labor
▫ Lasts 8 hours or less
▫ LATENT PHASE: Contractions must be 1 or more in 1o minutes, each lasting
20 sec or more
▫ ACTIVE PHASE: Contractions must be 2 or more in 10 minutes, each lasting
20 sec or more
▫ Cervical dilatation: The rate of cervical dilatation changes from latent to
active phase of labor
▫ The LATENT phase (slow period of cervical dilatation) is from 0-2 cm,
with a gradual shortening of the cervix
▫ The ACTIVE phase (faster period of cervical dilatation) is from 3-4cm
to 10 cm or full cervical dilatation
▫ Prolonged latent phase:
▫ Nulliparas: > 20 hours
▫ Multiparas: > 14 hours
▫ Management:
▫ Full assessment of maternal and fetal well-being
▫ Options:
 No action. If cervix is not 4cm or more dilated, the woman is
NOT in labor. Abandon partograph.
 Observation, rest and therapeutic analgesia as required.
  Establish a care plan to meet the woman’s needs either at
home or in non-laboring area of the health care facility. The
plan should include information about coping strategies, and
how and when to access support from care providers, when to
return for assessment, and take into consideration the time
required to transfer the woman to a higher-level health care
facility should this become necessary.
 Consider ARM (artificial rupture of membrane) with oxytocin if
medical indications are present
 Deliver by cesarean section only if fetal distress or other
factors are likely to lead to obstruction or the presence of other
medical complications necessitating termination of labor.

Starting the partograph

A partograph chart must only be started in the active phase, when the cervix is 4 cm
or more dilated

Abnormal Progress of labor

One of the main functions of the partograph is to detect early deviation from normal
progress of labor

Prolonged latent phase

o Women should NOT be admitted to a maternity unit in the latent phase of
labor unless there is a medical indication for admission. If admission is
required for a medical indication, the woman should be cared for in a non-
laboring area of the health care facility.
o The inappropriate use of active management of labor in the latent phase
leads to an increase in cesarean section s performed for dystocia, especially
in the nulliparous woman. Appropriate management of early labor could
result in a decrease in cesarean section rate.
o PROLONGED latent phase- if a woman is admitted in labor in the latent phase
(less than 3 cm) and remains in the latent phase for the next 8 hours

Prolonged active phase

o Moving to the right of the alert line
o In the active phase of labor, plotting cervical dilatation will normally
remain on, or to the left of the alert line. If the plot moves to the right
of the alert line, this is a warning that labor may be prolonged.
o When the dilatation moves to the right of the alert line and if adequate
facilities are not available to deal with obstetrical emergencies, the
woman must be transferred to a hospital unless she is near delivery.
o At the action line
o The action line is 4 hours to the right of the alert line. If a woman’s
labor reaches this line, a decision must be made about the causes of
 the slow progress, and appropriate action taken. This decision and
action must be taken in a hospital with facilities to deal with obstetric
emergencies.
o Definition: Cervical dilatation is <1cm/hour

Active Phase abnormalities

NULLIPARA MULTIPARA
PROTRACTION
CERVICAL DILATATION <1.2 cm/h <1.5 cm/h
DESCENT < 1 cm/h < 2 cm/h
ARREST
CERVICAL DILATATION 2 HOURS
DESCENT 1 HOUR
Failure of Descent No desscent in deceleration phase or 2nd stage of
labor

Partograph is NOT recommended in the following cases: Give initial

management then refer
• Ante-partum hemorrhage
• Pre-eclampsia and eclampsia
• Multiple pregnancy
• Severe anemia
• Fetal distress
• Malpresentation
• Very premature baby
• Obstructed Labor

Activity:
Case 1:
• Ana, G3P2 was admitted today at 2am, 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 10min). At 6am, the BOW ruptured
spontaneously with clear amniotic fluid. IE showed 8 cm dilated cervix. Vital
signs were the same. At 8 am, cervix was 9cm. She delivered spontaneously
at 8:30 am. 10u oxytocin was given IM. Placenta was delivered complete at
8:35am.
• Draw the partograph.
• What is the OB Score?
• Is this a normal labor? Why?
Case 2:
• Eva, a G1P0 was admitted at 6pm in a birthing clinic. BP=120/80,
PR=84/min, T=36.5, FHT=150/min, cervix 5cm dilated, intact BOW. She had
2-3 uterine contractions in 10 min. After 4 hours, IE showed 7cm dilated
cervix. Vital signs and FHT were the same. At 12 am, another IE done
showed 8cm dilated cervix, negative BOW, clear AF. FHT 140/min. Another
IE after 2 hours was the same, FHT 144/min. Vital signs were the same.
• Draw the partograph.
• Is this normal labor?
• If not, what is the abnormality of labor and what is your basis. I
• f you are the midwife on duty attending to the patient, what will be
your plan of management and Why?

Case 3
• Joy, a 40yo, G6P5(5004), 41 weeks AOG by LMP, was admitted 5am today
due to watery vaginal discharge. The cervix was 4cm, cephalic, (-) BOW, with
clear amniotic fluid, station (-) 2. At 9 am, repeat IE revealed cervix at 6cm
dilated, station 0, with clear amniotic fluid. Another IE done at 1pm full
cervical dilatation still at station 0. Repeat IE done at 2 pm revealed same
findings.
• Draw the partograph.
• Is this normal labor?
• If not, what is the abnormality?
• Based on the history, can this patient be managed in a birthing center?
Why or why not?