1. The Partograph 1

2. I. The Partograph A tool to help in management of labor
Guides birth attendant to identify women whose labor is delayed and therefore decide appropriate action
The partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor.

3. This is the SIMPLIFIED WHO partograph and the one that we will be using during this training.

4. OBJECTIVES To understand the concept of the WHO partograph
To explain to mothers the significance of the graph
To record the observations accurately on the graph
To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral

5. Monitor during labor… Progress of labor Maternal well being
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 6

6. The parts of the partograph
Progress of labor
The upper colored portion is where you plot the progress of labor.
The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.
Maternal and fetal well-being 7

7. DILATATION
Alert line
Let us enlarge the upper portion of the partograph. As you can see it is divided evenly into small boxes by gridlines vertically and horizontally.
Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to 10.
While the vertical gridlines indicate the time, in hours, the patient is in active labor.
The upper portion is also divided into 3 colors – green, yellow, and red.
The boundary between the green and yellow parts forms a diagonal line which is highlighted here. This is designated as the alert line which starts at 4 cm. up to 10 cm.

8. Parallel and 4 hours to the right of alert line
DILATATION
Alert line
Action line
Parallel and 4 hours to the right of alert line
Parallel and 4 hours to the right of the alert line is another line formed by the boundary between the yellow and red part which is again highlighted here. This is the action line. Note that it too starts at 4 cm and ends in 10 cm.

9. 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
The partograph need not be used in all pregnant or laboring patients especially those who are for cesarean delivery like those with malpresenting babies (breech or transverse lie), those with scarred uteri, those with antepartum hemorrhage (like placenta previa). It is also not needed in those who have to be delivered immediately because of fetal distress or those with severe uncontrolled pre-eclampsia and eclampsia. Likewise it may not be appropriate for those with twins or very premature baby.

10. II. Recording the findings in the partograph
Start by labeling the record with pertinent patient identifying information.

11. 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)

12. Start plotting on alert line in the intersection corresponding cervical dilatation finding13

13. X
You do not always have to start the plotting in the 4 cm line since not all patients are first seen at this cervical dilatation. If the patient arrives at 6 cm cervical dilatation start plotting in the 6 cm line but still in the alert line. 14

14. X
If she is first seen at 8 cm, then start at the 8 cm line but still on the alert line. 15

15. X
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

16. X 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 17

17. Connect the “X”s to demonstrate the pattern of labor
4pm
8pm
10pm
Connect the “X”s to demonstrate the pattern of labor

18. EXAMPLE x
1am
A G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix.
Encourage audience participation. 19

19. EXAMPLE x x
1am
5am
At 5 am, another IE showed 9 cm dilated cervix. 20

20. EXAMPLE At 7 am, the patient is 10 cm dilated, intact BOW. x x x 1am21

21. III. Distinguishing normal from abnormal labor pattern

22. X X 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)

23. X X
4cm = active labor X
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. 24

24. X 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

25. 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 26

26. 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
EmOC facility is a hospital with capability for Emergency Obstetric Care.

27. Maternal and fetal well-being
Progress of labor
The upper colored portion is where you plot the progress of labor.
The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.
Maternal and fetal well-being 28

28. As I have said below the colored part is where you are supposed to write your other observations such as the character of the amniotic fluid, the number of contractions in 10 minute period, the FHR per minute, whether the mother voided or not, her axillary temperature in centigrade, her pulse rate per minute, her BP, whether the patient is on oxytocin or not, and the patient’s other problems if any. 29

29. IV. Other findings to note (and record) during IE
Status of membranes, write
“ I ” if intact
If ruptured, note color of amniotic fluid, write
“ C ” if clear
“ M ” if meconium stained
“ A ” if absent
“ B ” if bloody

30. Monitor every 4 hours* and record the findings
Blood Pressure
Pulse rate
Temperature
Urine voided (yes or no)
* More frequently, if indicated

31. Monitor more frequently and record the findings
Number of contractions in 10 minute period
Fetal heart rate in 1 full minute
The findings for these should be recorded every hour.

32. If woman is admitted in LATENT PHASE of labor (less than 4 cm dilated) – record only other findings (BP, FHT etc).
If she remains in latent phase for next 8 hours (labor is prolonged), transfer her to hospital. 33

33. EXERCISES
Indicate whether the progress of labor in the following partographs are normal or abnormal.

34. x
Case 1 x
10pm
2am
Normal

35. Case 2 X X X X
8pm
12mn
2am
4am
Abnormal

36. X
Case 3 X x
9pm
1am
3am
Normal

37. EXERCISES
Plot the observations in the following cases.

38. 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.
Give the participants 3-5 minutes to answer this exercise.

39. Maria, G1P0 Date Today X X X X 2am 6am 8am I 3 140 140 88 88 8:30 CI
Check the answers individually. C 3
140
140 88 88
110/70
110/70
8:35
8:30

40. 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, PR-92/min, T-37.5, FHT-140/min
Give the participants 3-5 minutes to answer this exercise.

41. Lourdes, G4P2 Date Today X X X 5pm 9pm 1am M 3 3 36.5 36.5 37.5 120/80
Check the answers individually. M 3 3
36.5
36.5
37.5 80 80 92
120/80
120/80
110/70

42. 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
Give the participants 3-5 minutes to answer this exercise. 43

43. Marites, G1P0 Date Today X X X X 6pm 10pm 12am 2am 2 I I C C 2-3 3 140
Check the answers individually. I I C C
2-3 3
140
140
140
144
36.5
36.5
36.5 84 84
120/80
120/80
120/80 5 7 8 44

44. 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

45. Good day! 46