PRACTICAL PARTOGRAPHY

Assoc Prof Dr Hanifullah Khan

Partograph
• A graphical record of
labour
• Purpose
– To chart the progress of
labour
– To chart important
events during labour
– To chart maternal &
fetal condition
• WHO developed
 Why do we need one?
• For early detection of abnormal progress of labour
• Recognition of CPD
• Can allow time & discussion of further management of
labour
• Make observations & recording of fetomaternal condition
more objective
• Prevention of fetomaternal problems & complications
Components of the partograph
• Can be divided into 3
parts
– Part I : fetal condition
( at top )
– Part II : progress of
labour ( middle )
– Part III : maternal
condition (bottom )
FETAL CONDITION
 Overview

o This part of the graph is used to monitor the fetus

o Fetal well-being is assessed via charting of
o Fetal heart rate
o membranes and liquor
o moulding the fetal skull bones
 Fetal charting
Fetal heart Membranes & Liquor
Basal fetal heart rate • intact membranes … I
• brady>110-160<tachy • ruptured membranes
Decelerations? yes/no • + clear liquor …….. C
Relation to contractions? • ruptured membranes +
 Early meconium liquor … M
 Variable • ruptured membranes +
 Late
bloody liquor …….. B
• ruptured membranes +
no liquor………….. A
Moulding
• The fetal skull is made up
by a number of bones
divided by sutures
• These bones only fuse
after birth
• This is to allow the bones
to overlap during delivery
– Decrease the diameter
• The overlap of the bones is
termed moulding
• In short, moulding allows
the pelvis to accommodate
the fetal head
 Moulding on the Partogram
• Increasing moulding suggests cephalopelvic
disproportion (CPD)
• Marking on the partogram is as follows:

Extent of moulding as marked on Partogram

separated bones, sutures felt easily 0
bones just touching each other +
overlapping bones, reducible ++
severely overlapping bones, non-reducible +++
Charting fetal well-being
Note the progressive bradycardia, liquor change & worsening
moulding
LABOUR PROGRESS
Components
Cervical
dilatation

Descent
of head

Time
The main feature of this section is the graph of
cervical dilatation against time
Contractions Note the division between latent & active phases
 Phases of labour
• Labour is not a continuous process
– Begins slowly & becomes faster with time
• Important to recognize this fact
– Measured objectively from 0-10 cm cervical dilatation
– This is Stage I
• Initial slow part is termed the latent phase
– Coincides with the taking up & effacement of the Cx
– Objectively, from 0 to 4 cm cervical dilatation
• The faster part is active labour
– This is all about cervical dilatation
– From 4 -10 cm dilatation
 Cervical dilatation
• One way of assessing
progress of labour
• The firm & long Cx
becomes soft & shorter
towards term
• The important dilatation
is with reference to the
internal os
• Dilatation in concert
with contractions
denotes labour
 Charting dilatation
• The vaginal examination will
decide if the patient is in the
active or latent phase
• In the active phase of labour ,
recording of cervical
dilatation starts on the alert
line
• The alert line drawn from 4 cm
dilatation represents the rate of
1cm/hour
• The action line is drawn 4
hrs to the right of the alert • If she is in latent phase,
charting is done from the
line and parallel to it beginning (0 time)
– This is the critical line at – when the active phase of
which specific management labor begins, recording is
decisions must be made transferred to the alert line
– In normal labour, plotting of
cervical diltation remains on
the alert line or to left of it
 From latent to active phase
• If the pt passes from latent to
active phase in < 8 hours
– transfer plotting of cervical
dilatation to the alert line
using the letters TR
• Leave the area between the
transferred recording blank.
– The broken transfer line is not
part of the process of labor
• If she is in latent phase,
• Do not forget to transfer all
charting is done from the
other findings vertically
beginning (0 time)
– when the active phase of
labor begins, recording is
transferred to the alert line
• when a woman ,s partograph reaches the action line , she must
be carefully reassessed to determine why there is lack of
progress , and a decision must be made on further management
( usually by an obesterician or resident )

• when a woman in labor passes the latent phase in less than 8

hours i.e., transfers from latent to active phase , the most
important feature is to transfer plotting of cervical diltation to
the alert line using the letters TR,

• Leaving the area between the transferred recording blank. The

broken transfer line is not part of the process of labor

• do not forget to transfer all other findings vertically

 Descent of the fetal head
• Assessed abdominally
• Using the rule of fifth to assess
engagement
– Assess how much of the head is
still felt per abdomen
• When only 2/5 or less of the
fetal head palpated above the
level of symphysis pubis , this
implies the head is engaged
– The vertex has passed or is at the
level of ischial spines
 Station
• Assessing descent of the
fetal head by vaginal
examination
• The ischial spines are
the reference point
• In cephalic presentation,
the Vertex is used to
assess progress
• Station 0 – level of the
spines
This is the most important indicator of
progress
Position
The vertex presentation is further classified according to the position
of the occiput
Charting Dilatation & Descent

Crossing the
action line

diltation of the
cervix is plotted with
No descent Dilatation an X ,
arrested desent of the fetal
head is plotted with an
O
uterine contractions
are plotted with
Note the time differential shading
 Uterine contractions
• Uterine contractions should increase progressively
• Effect of the pressure of the head on the upper vagina
(Ferguson reflex)
• The frequency, duration & intensity are recorded
• May be recorded as the no. of contractions/10 min
• Observations of the contractions are made every hour in
the latent phase and every half-hour in the active phase
 Charting Uterine contractions
• Measured in seconds from the time the
contraction is first felt abdominally , to the time
the contraction phases off
• Each square represents one contraction
• Correlation with oxytocin use important

Palpate number of
contraction in 10 minutes
& duration of each
contraction in seconds

Between 20 & > 40 seconds

40 s
MATERNAL CONDITION
 Note the components

Drugs e.g.
opiates/oxytocics

Vital signs
Urine monitoring
SOME EXAMPLES
 Prolonged latent phase
• A prolonged latent phase may denote problems & require
attention
• A heavy line is drawn on the partograph at the end of 8
hours of the latent phase
 Polonged Active phase
• Movement of the
dilatation charting beyond
the alert line may denote
obstruction
• Do not just focus on the
dilatation alone
• Other aspects such as
descent, fetal heart rate,
liquor character &
moulding must be taken
together
Secondary arrest of cervical diltation

• This may denote midcavity

or outlet obstruction
Secondary arrest of head descant

• Another example
 Important points
• It is important to realize that the partograph is a tool for
managing labor progress only
• It does not help to identify other risk factors that may have
been present before labor started
• Charting is only done when the pt is in labour
 Diagnosis of labour

Regular painful contractions resulting

in progressive change of the cervix

+/- show
+/- rupture of membranes

Does not denote labour!