PARTOGRAPH

DR ODOFIN J.T
Registrar
Department of Obstetrics & Gynaecology
FEDERAL MEDICAL CENTER,Ebute-Metta
 OUTLINE
• Introduction
• Definition of Partograph
• History of Partograph
• WHO Partograph
• Principles of WHO Partograph
• Advantages of Partograph
• Components of the Partograph
• Charting & Closing of Partograph
• Indications & Contra-indications to its use
• Limitations of Partograph
• Overcoming obstacles to its use
• Conclusion
• References
 INTRODUCTION
• Every year because of complications of pregnancy,
approximately half a million women loss their
lives, and about 99% of these occur in developing
countries.
• The risk of a woman dying as a result of a
complication related to pregnancy in developing
countries can be as much as a hundred times that
of women in Western Europe or North America.

• An average of 450 women die for every 100 000

live births in the developing world.
 INTRODUCTION
• Postpartum haemorrhage and sepsis are the
most common causes of maternal death in
developing countries but, Obstructed labour
and ruptured uterus contributes up to 70% of
maternal mortality.
• Early detection of abnormal progress and
prevention of prolonged labour can
significantly reduce it
• Tools and techniques to monitor labour thus
play an important role in saving women’s lives.
 Introduction contd
• The Safe Motherhood Conference organized
jointly by The World Bank, WHO and the United
Nations Population Fund held in Nairobi in
February 1987 concluded with a“Call
to Action.”
• This call demands that health workers involved in
the care of mothers and children
take positive action now to reduce maternal
mortality and morbidity.
• Among the actions called for are:
 Intoduction contd
• To ensure that all pregnant women are
screened by supervised and appropriately
trained non-physician health workers where
appropriate, with relevant technology
(including partographs as needed),
• To identify those at risk; and to provide
prenatal care and care during
labour, as prompt as possible.
 introduction
• A goal of MDG 5 is to reduce maternal mortality and have a
skilled attendant at every birth by 2015. A critical skill in
ongoing intrapartum monitoring of labour progress and
maternal/fetal well-being.

• The Recommendation 8 in the Third Report on Confidential

Enquires into Maternal Death in South Africa 2002-2004 in
which 3406 deaths were analysed to show primary obstetric
cause of death, concerns the correct use of partograph which
should be the norm in each institution conducting birth.

• Partograph aids the principle of Active Management of

Labour.
 DEFINATION OF PARTOGRAPH
• Partograph is a Greek word meaning “Labor
Curve”. It is a graphic recording of progress of
labor and salient features in the mother and
fetus.
• It detects labor that is not progressing normally,
indicates when augmentation of labor is
appropriate.
• It recognizes cephalo-pelvic disproportion long
before labor becomes “obstructed”,which may
result in obstructed labour, and its sequelea:
 DEFINATION OF PARTOGRAPH
• maternal dehydration, exhaustion, uterine
rupture and vesico-vaginal fistula.
• It serves as an ‘early warning system ‘and
assists in early decision making on transfer,
augmentation and termination of labour.
• It is usually a single sheet of pre-printed paper.
Electronic partographs are becoming more
widespread and can be built into medical
records systems ,or as part of medical software
packages especially in high resources settings.
 HISTORY OF PARTOGRAPH
• FRIEDMAN-1954:
-First described a normal graphic cervical
dilatation pattern which is Sigmoid in nature.
-First stage of labour was functionally divided
into:
-Early/Latent phase
-Active phase-rapid dilatation &deceleration
phase.
HISTORY OF PARTOGRAPH
 HISTORY OF PARTOGRAPH
• HENDRICKS 1969:
- found similar curves(varies little) between
Primigravidae&Multigravidae.
-did not find the deceleration phase.
• PHILPOT&CASTLE:
-added the preset lines(Alert&Action lines)
-added the “Transfer line” which was 2hours
to right of the Alert line. He therefore
provided sound scientific basis for early
intervention leading to prolonged labour.
 HISTORY OF PARTOGRAPH
• CRICHTON 1974:
- added the Descent of the head in Fifths notation.
• FRIEDMAN -1975-78:
-did not find the Deceleration phase.
• JOHN STUDD:
- used a stencil to show the cervical dilatation from Time
zero.
• BEAZLEY&KURJAK:
-modified the partograph to commence at first vaginal
examination and end at delivery.
 HISTORY OF PARTOGRAPH

• WHO -1994
- devised the composite partograph.
• WHO -2000
-produced the modified/simplified
partograph.
 WHO COMPOSITE PARTOGRAPH
• The first WHO partograph or ‘Composite
partograph’: covers a latent phase of labour of
up to 8 hours and an active phase beginning
when the cervical dilatation reaches 3 cm.

• The active phase is provided with an alert line

and an action line, drawn 4 hours apart on the
partograph as aids to monitoring labor.
 WHO COMPOSITE PARTOGRAPH
• This partograph is based on the principle that
during active labor, the rate of cervical
dilation should not be slower than 1 cm/hour.

• A lag time of 4 hours between slowing of

labour and the need for intervention is unlikely
to compromise the fetus or the mother and
avoids unnecessary intervention.
 WHO COMPOSITE PARTOGRAPH
• Since a prolonged latent phase is relatively
infrequent and not usually associated with
poor perinatal outcome, the usefulness of
recording the latent phase of labour in the
partograph has been questioned.

• Moreover, differentiating the latent phase from

false labour being difficult, diagnosis is often
made in retrospect.
 WHO COMPOSITE PARTOGRAPH
• To alleviate these disadvantages,a WHO
‘Modified Partograph’ was introduced by
removing the latent phase and considering
the beginning of active phase at 4 cm
dilatation of cervix instead of 3 cm.
• There were some other minor changes which
include considering two squares in 1 hour
instead of one square in 1hour in cervical
dilatation curve.
WHO COMPOSITE PARTOGRAPH
WHO COMPOSITE PARTOGRAPH
WHO MODIFIED PARTOGRAPH
 STUDY
• To compare two World Health Organization
(WHO) partographs : composite partograph
with latent phase with a simplified(modified)
one without the latent phase in women with
uncomplicated pregnancy.
Results:
• Labour values crossed the alert and action
lines significantly more often when composite
partograph was used in each, with increased
number of augmentations.
 Result contd.
• The number of vaginal deliveries were high in
the simplified group. There was no significant
difference in the rate of cesarean deliveries due
to non progress of labor in both groups.

• Most resident doctors (93%) experienced

difficulty with the composite partograph, but
no resident doctor reported difficulty with the
simplified partograph.
 Result contd
• The mean SD user friendliness score was
lower for the composite partograph.
Conclusion of the Study:
The WHO simplified partograph is easier to use
and is a better option for both the laboring
women and the users, when compared to
composite partograph.
• (J Turkish-German Gynecol Assoc 2011; 12:
31-4)
 ADVANTAGES OF PARTHOGRAPH
Introduction of the partograph with an agreed labour
management protocol- Improved Labour Outcome:
• Reduced prolonged labour (from 6.4% to 3.4% of labours)
• Reduced the proportion of labours requiring augmentation
(from 20.7% to 9.1%).
• Emergency caesarean sections fell from 9.9% to 8.3%, and
• Intrapartum stillbirths dropped from 0.5% to 0.3%.
• Among singleton pregnancies with no complicating factors,
the improved outcome was even more marked, with
caesarean sections falling from 6.2% to 4.5%.
 ADVANTAGES OF PARTOGRAPH
• It allows easy and early recognition of abnormal
progress of labour with timely intervention
which leads to safe motherhood worldwide.
• It allows management of all phases of first stage
of labour.
• It aids prompt referral of impending labour
problem from the peripheral health center to a
center with expertise/facility.
• It is a good tool for teaching and also makes
handing over of shifts in labour to be simplified.
 ADVANTAGES OF PARTOGRAPH
• It is time-saving and more efficient than
other methods of recording labour features.

• It is simple and skill in its use can be acquired

quickly.

• It is an undisputable evidence of how labour

was managed. Proper management or
otherwise can be picked up at a glance.
PRINCIPLES BEHIND THE USE OF THE WHO PARTOGRAPH
• The latent phase of labour occurs up to 4cm dilatation.

• The Active Phase starts at 4cm and ends at full cervical

dilatation of 10cm.

• The Latent Phase should not last longer than 8 hours.

• The cervical dilatation in the Active Phase should be at

least one(1)cm per hour.

• A lag time of 4 hours between slowing of the labour and

the need for intervention is unlikely to compromise the
fetus or the mother,and therefore avoids unneccessary
intervention.
01/05/2022 28
 PRINCIPLES BEHIND THE USE OF THE WHO PARTOGRAPH
• A recommended Vaginal Examination interval of 4
hours as compatible with safe practice.
• There are preset lines(The Alert &Action lines)drawn
parallel to each other with 4 hours interval between
them and at a gradient of 1cm per hour.

• It is good in detecting deviations from normal labour

but does not replace careful assessment of the
mother & fetus.

• It is can be used for all labours in hospital but at

primary care level, it is indicated for only low risk
labours. High risk patients need hospital care.
01/05/2022 29
COMPONENTS OF PARTHOGRAPH
• The patient’s information- name, Hosp. number,
Date& Time of admission into the 1st stage room,
Gravidity, Parity,type of Rupture of membrane with
time in hours are all noted on the space provided.

• There are 3 components of Partograph:

1. The fetal condition: fetal heart rate, membranes
and liquor and moulding of fetal skull.
2. The progress of labour: cervical dilatation, descent
of fetal head, and uterine contractions.
3. The maternal condition: pulse rate, blood pressure,
temperature, urine, drugs, IV fluids, and oxytocin.
 FETAL COMPONENT
• The fetus is monitored closely on the
partograph by regular observation of the fetal
heart rate(every 5min./15min./30min.), the
liquor(intact or ruptured:clear fluid, blood or
meconium stained) and the
moulding(0,1+,2+,3+) of the fetal skull bones.
• A gradual increase in the basal FHR
or prolonged bradycardia indicates the
possibility of fetal distress. FHR:<120 or >160-
listen every15min.if still abnormal after 3
observations-take action unless delivery is
imminient.
 The fetal condition contd:
• The colour of the amniotic fluid if heavily
stained with meconium, with scanty fluid or
fresh passage of meconium, or the absence
of amniotic fluid at the time of the rupture of
membranes is suggestive of possible hypoxia.
• These observations are made at each vaginal
examination 4 hourly.
 LABOUR PROGRESS COMPONENT
• The most important parameters of progress of
labour are: observing the progressive
effacement and dilatation of the cervix and the
descent of the presenting part against time in a
chronological manner.Both 4 hourly.

• The frequency and duration of uterine

contractions are also noted half-hourly.
 LABOUR PROGRESS CONTD
1. Cervical dilatation:
The rate of dilatation of the cervix changes
during labor, this is represented by the bold
lines in the graph.

• Dilatation of the cervix is measured by the

diameter in cm. This is recorded with an X in
the center of the partograph, at the
intersection of vertical and horizontal lines.
 Cervical dilatation contd
• The vertical scale represents dilatation by 10
squares of 1 cm each. The horizontal scale
represents time by 24 squares of one hour
each.

• When labour goes from latent to active phase,

the dilatation must be plotted on the alert
line(composite partograph). The latent phase
should normally not take longer than 8 hours.
 Cervical dilatation contd
• When admission takes place in the active
phase, the dilatation is immediately plotted on
the alert line.

• If progress is satisfactory, the plotting of the

cervical dilatation will remain on or to the left
of the alert line.
 LABOUR PROGRESS CONTD.
2.Descent of fetal head:
• Descent of the fetal head may not take place
until the cervix has reached about 7 cm of
dilatation.
• This is measured by abdominal palpation and
expressed in number of finger widths (fifths
of the head) above the pelvic brim.
• It is also recorded in the central part of the
partograph with an "O".
DESCENT/STATION OF FETAL HEAD
FETAL HEAD DESCENT IN FIFTHS
 UTERINE CONTRACTION
• This is elicited by abdominal palpation of the
contraction each time it occurs.
• The frequency of its occurrence in 10 minutes
and duration of each in seconds are noted.
• Each box represents 1 contraction with the
following shade-
• <20 seconds: dots
• 20-40 seconds: crosshatch
• >40 seconds: blackout
UTERINE CONTRACTIONS
 MATERNAL COMPONENT
• The maternal condition is monitored by
observing the pulse(half hourly), blood
pressure(4 hourly), temperature(2 hourly)
and hydration.
• In addition, the use of anesthetic and
oxytocic drugs can be recorded in the
partogram.
• Record urine volume(encourage to pass urine
2-4 hours) and do urinalysis for Protein and
Acetone.
 INDICATIONS FOR THE USE OF THE PARTOGRAPH

• USED FOR WOMEN IN LABOUR WITH GESTATION GREATER

THAN 34 WEEKS.
• THOSE ADMITTED IN LABOUR.
– LATENT PHASE OF LABOUR (CERVIX < 3 - 4CM) WITH REGULAR PAINFUL
CONTRACTIONS AT LEAST 2 IN 10 MINUTES AND LASTING AT LEAST 20
SECONDS.
– ACTIVE PHASE (CERVIX > 3 – 4 CM) WITH REGULAR PAINFUL
CONTRACTIONS OF AT LEAST 1 IN 10 MINUTES LASTING AT LEAST 20
SECONDS.
• THOSE ADMITTED WITH SPONTANEOUS RUPTURE OF
MEMBRANES BUT NO CONTRACTIONS.
– WHEN OXYTOCIN IS STARTED
– WHEN LABOUR COMMENCES
• THOSE WHO ARE INDUCED
– ARM WITH OR WITHOUT OXYTOCIN.
– MEDICAL INDUCTION WITH OXYTOCIN ONLY, PROSTAGLANDIN OR
CATHETER.

01/05/2022 43
 CONTRAINDICATIONS TO ITS USE

THE PARTOGRAPH SHOULD NOT BE USED FOR THE

FOLLOWING CONDITIONS:
• ADMISSION CERVICAL DILATATION OF 9-10 CM.

• THOSE SCHEDULED FOR ELECTIVE CAESAREAN SECTION.

• THOSE GOING FOR EMERGENCY CS IMMEDIATELY ON

ADMISSION.
• PATIENTS WITH GESTATIONAL AGE LESS THAN 34
COMPLETED WEEKS.

01/05/2022 44
 CHARTING ON THE GRAPH
• This entails the use of different marks to chart
the corresponding values on the right place on
the graph.
• for example-X for the cervical dilatation. O:for
descent.Dot(.):FHR,PR.Arrow ^: for systolic
BP etc.
• All these marked values for respective
parameters will be joined together while
closing the partograph.
• The summary of the delivery is the written .
Closed partograph
 LIMITATIONS TO ITS USE
• The use of partographs is most common in
hospitals (rather than clinics or maternity
homes) in low-resource settings.
• Beyond hospitals, a study of health extension
workers and midwives in peripheral delivery
units in Nigeria found that only 10% of
caregivers consistently used the partograph,
and even fewer used it correctly.
• Correct use may be limited by training, time,
and caregiver skill level. In many cases, literacy
and numeracy are barriers to its broader use.
 OVERCOMING OBSTACLE TO ITS USE
• The Use the simplified partograph developed by WHO. It includes
the essential features of most of the partographs currently in use.
• Introduction of this partograph to decision-makers at Ministries of
Health,as well as to leaders of the profession in each country,
especially to those in teaching hospitals.
• Implement this partograph initially in teaching hospitals and
referral centres. Its application can then be extended to health
centres.
• Encourage medical and midwifery schools to teach the principles
and use of the partograph, and to include it in the curriculum.
• Encourage research into all aspects of the application of the
partograph.
 OVERCOMING OBSTACLE CONTD.
• Research should be encouraged to include
evaluation of training programmes, as well as
investigation of the impact of the partograph on
labour management and on adverse outcomes of
labour.
• By extention,It is realized that in many developing
countries the formal health care system does not
look after all pregnant women. Therefore efforts
should be made to reach pregnant women outside
the formal health care system.
 OVERCOMING OBSTACLES CONTD
• Training and re-training of personnel in the
primary health center in its use is very ideal.
This is evident in the study:Impact of Training
on the Use of Partograph on Maternal and
Perinatal Outcome in Peripheral Health
Centers.
• Ernest Okechukwu ORJI, Adesegun A
FATUSI,Niyi O MAKINDE, Babalola A ADEYEMI,
Uche ONWUDEGWU
Department of Obstetrics and Gynecology,
Obafemi Awolowo University, Ile-Ife, Nigeria
 Study contd.
• Data on labour outcome on 242 labouring
women who fulfilled inclusion criteria were
collected prior and post training of fifty-six(56)
healthcare workers in the use of WHO
partograph.
Result: There was increase in transfer in labour
but reduction in the duration of labour ,
obstructed labour ; postpartum
hemorrhage,genital sepsis; perinatal mortality ,
and better neonatal Apgar scores at 1 and 5
minutes after introduction of partograph.
 Result of study contd
• Though augmentation of labour increased and
caesarean section rates decreased following
partograph use.

• There was one uterine rupture and 2 maternal

deaths before introduction of partograph but
none after partograph introduction.
 Conclusion of the study

• Introduction of partograph in peripheral

health units in a developing country reduced
labour complications with resultant reduction
in maternal and perinatal mortality and
morbidity.
 OVERCOMING OBSTACLES CONTD.
• Traditional birth attendants (TBAs) should be
involved as much as possible as agents of
change(not to use Partograph but for early
referral of high risk patients).

• It is hoped that the improved results in labour

management that should result from the use of
the partograph will increase the credibility of
the formal health care system and encourage
more women to seek assistance early in labour.
 CONCLUSION
• In reducing the high alarming rate of maternal
mortality and morbidity, the correct use of
partograph will go a long way to effect this.
• Partograph is a tool which proves useful in the
hand of a competent skill caregivers. There
should then be careful assessment of the
labouring women. And every unit where it is
being used should have a management
protocol so as to help the user to know what
to in good time.
 References
• Emuveyan. The partograph.Comprehensive
Obstetrics in the Tropics.,9:68-76.
• WHO: Maternal Mortality in 2000: Estimates
Developed by WHO,UNICEF, and UNFPA.
• Philpott R.H. Graphic records in labour. British
Medical Journal 1972; 4: 163-5. .
• Alauddin Md, Runa Bal, Arunangsu De,
Parthajit Mandal, Mayoukh Chakraborty.
Monitoring of labor with WHO modified
partogram -A study report. NJOG 2008;3:8-11.
• Update course 4Part 1 WACS-2012:Partograph
 References
• Maternal Mortality Rates - A Tabulation of
Available Information 2nd edition, WHO
document FHE/86-3
• WHO partograph cuts complications of labor
and childbirth. Safe Mother 1994 Jul-Oct;
(15):10.
• JE Mathews, A Rajaratnam, A George, M
Mathai. Comparison of two World Health
Organization (WHO) partographs. Int J
Gynecol Obstet 2007 Feb; 96(2):147-150
 References
• Mathai and Matthews . The Partograph for
the Prevention of Obstructed Labor. Clincal
Obstet Gynecol, June 2009; 52(2): 256-69
• World Health Organization. Preventing
Prolonged labor: A Practical Guide. The
Partograph. Maternal Health and Safe
Motherhood Programme, Geneva,1993 , WHO
document WHO/FHE/MSM/93.8.(s) 
• Anna Nolte. The Partograph and How to assess
labour.Professional Nurses Series.2008
 References
• Orji E.O, Fatusi A.A, Makinde N.O et al.
Impact of Training on the Use of Partograph on
Maternal and Perinatal Outcome in Peripheral
Health Centers,
• 148 J Turkish-German Gynecol Assoc, Vol. 8(2);
2007:148-152
• OT Oladapo et al. Knowledge and use of the
partograph among healthcare personnel at the
peripheral maternity centres in Nigeria. Journal
of Obstetrics and Gynaecology. 2006 Vol. 26,
No. 6, 538-541.
 References
J Neilson et al. Obstructed Labor. British Medical
Bulletin. 2003; 67:191-204.
G. Dangal : Preventing Prolonged Labor by Using
Partograph . The Internet J of Gyn and
Obstetrics. 2007.
The Partograph: A Managerial Tool for the
Prevention of Prolonged Labour. WHO. Geneva
1988.
Akin Agbola: The Partograph. Textbook of
Obstetrics and Gynaecology for Medical
Students.2nd Edition.2006;34:295-300.
THANK YOU FOR YOUR
ATTENTION