Partograph

Rendy Adhitya Pratama

Partograph
Use partograph to monitor progress of
labour at all women admitted to labour
ward
Women should not be admitted for labour
ward until in active labour
Active labour is when women have regular
contractions (3-5 in ten minutes) and
cervix is 4 cm. dilated
WHO Partographs: Original and Simplified
Original WHO Partograph
Simplified WHO Partograph
WHO Partographs: Differences
Original WHO Partograph
Simplified WHO Partograph
Components of the partograph
Fetal condition:
-fetal heart rate
-membranes and liquor
-moulding
Progress of labor:
-cervical dilation
-descent of the fetal head
-uterine contractions
Maternal condition:
-pulse, blood pressure, temperature
-urine
-drugs and IV fluids
-oxytocin regime

Part 1 : Fetal condition

this part of the graph is used to monitor
and assess fetal condition:
1. Fetal heart rate
2. membranes and liquor
3. molding the fetal skull bones. Caput
Fetal Heart Rate:
Assess after contraction for 60 seconds:
Each 30 minutes in first stage (each 15
minutes if risk factors are identified
Each 5 minutes when pushing
Membranes and Liquor
intact membranes ....I
ruptured membranes + clear liquor ..C
ruptured membranes + meconium- stained liquor .....M
ruptured membranes + blood stained liquor B
ruptured membranes + absent liquor....A

Remember: the diagnosis cephalopelvic
disproportion cannot be made with intact
membranes!

Molding the fetal skull bones
Molding is an important indication of how adequately the
pelvis can accommodate the fetal head. Increasing
molding with the head high in the pelvis is an ominous
sign of Cephalopelvic disproportion.
separated bones . sutures felt easily.O
bones just touching each other..+
overlapping bones ...++
severely overlapping bones ( notable ) ..+++

Part 2 : progress of labour
this section of the paragraph has as its central feature a graph
of cervical dilation against time

Cervical dilatation
Descent of the fetal head
Uterine contractions

it is divided into a latent phase and an active phase


Cervical Dilatation
Assessed each 4 hours (or before if a crossed
action line is anticipated)

Alert Line:
Start recording cervical dilatation in the alert line.
As long as dilatation is 1 cm or more/hr the alert
line is not crossed.
If cervical dilatation is < 1 cm/hr the alert is
crossed and causes of prolonged labour should
be considered: always consider: artificial rupture
of membranes and augmentation with oxytocin.
Cervical dilatation
Action Line:
If the action line is crossed the actions
should be as follows in mentioned order (if
not already performed)
ARM and oxytocin augmentation
Correction of malposition
Cesarean Section or Vacuum (if in second
stage and descend is 1/5 or below)
Descent of the fetal head
It should be 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
Contractions:
Chart every 30 minutes
Number/10 minutes and Duration
Weak: Lasting <20 seconds
Medium: Lasting 20-40 seconds
Strong: Lasting >40 seconds
Oxytocin:
Record oxytocin (amount/volume) and
drops / minute
Dilatation of the cervix is plotted ( recorded with an X,
descent of the fetal head is plotted with an O , and
uterine contractions are plotted with differential
shading
Part 3 : maternal condition
pulse, blood pressure, temperature
urine
drugs and IV fluids
oxytocin
Management of labour using
the partograph
Diagnosis of labour

Regular painful contractions resulting in
progressive change of the Cervix
+/- show
+/- rupture of membranes
Components of normal labour
Patient
pain , bladder empty , dehydration , exhaustion
Powers
Uterine contractions
Maternal effort
Passages
Maternal pelvis ( Inlet - Outlet )
Maternal soft tissue
Passenger
Fetal ( size - presentation - position Moulding)
cord
placenta
membranes


If labor progresses
normally:

Do not need oxytocin
augmentation or other
intervetion, unless
complications develop.

Can do ARM (artificial
rupture of membranes)
during active phase



If between Alert and Action Lines:
This means warning

In health center, transfer to facility with C-section
capability, unless cervix is almost completely dilated.

Observe labor progress for short period before
transfer.

Continue routine observations.

ARM can be performed if membranes are still intact.
If At or Beyond Action Line:
This means danger - - decision
needed on management by
obstetrician or resident.

Conduct full medical
assessment
Consider IV,
catheterization, pain
medication
Deliver by C-section if
there is fetal distress or
obstructed labor
Augment labor with
oxytocin by IV if there are
no contraindications


ABNORMAL PROGRESS OF LABOR
One of the main functions of the
partograph is to detect early deviation
from normal progress of labor

Prolonged Active phase
Secondary arrest
of cervical
dilatation
Secondary arrest of head descent



POINTS TO REMEMBER
It is important to realize that the partograph is a
tool for managing labor progress only

The partograph does not help to identify other risk
factors that may have been present before labor
started
Only start a partograph when you have
checked that there are no complications of
pregnancy that require immediate action

A partograph chart must only be started when
a woman is in labor, Be sure that she is
contracting enough to start a partograph

If progress of labor is satisfactory, the plotting
of cervical dilatation will remain or to the left of
the alert line

When labor progress well, the dilatation should
not move to the right of the alert line


When admission takes place in the active
phase, the admission dilatation, is immediately
plotted on the alert line


Descent of the head should always be assessed by
abdominal examination ( by the rule of fifths felt
above the pelvic brim ) immediately before doing a
vaginal examination

Assessing descent of the head assists in detecting
progress of labor

Increased molding with a high head is a sign of
Cephalopelvic disproportion
Vaginal examination should be performed
infrequently as this is compatible with safe
practice ( once every 4 hours is
recommended )

When the woman arrives in the latent phase ,
time of admission is 0 time

A woman whose cervical dilatation moves to
the right of the alert line must be transferred
and managed in an institution with adequate
facilities for obstetric intervention , unless
delivery is near
OXYTOCIN
Oxytocin should be titrates
against uterine contractions
and increased every half- hour
until contractions are 3 or 4
in10 minutes , each lasting 40
50 seconds

Stop Oxytocin infusion if there
is evidence of uterine
hyperactivity and / or fetal
distress

Augment with Oxytocin only
after artificial rupture of
membranes and provided that
the liquor is clear
CASE STUDY: Mrs. A
Step 1:
Mrs A. was admitted at 5:00 am on 5/9/2014
Her membranes ruptured at 4:00 am
Gravida 3, para 2
Hospital number 567886
On admission, the fetal head was 4/5 palpable
above the pelvic bone and the cervix was 2 cm
dilated.

What should we record on the partograph?
CASE STUDY: Mrs. A
Step 2:

09:00 am
The fetal head is 3/5 palpable above the
pubic bone
The cervix is 5 cm dilated

What should we record on the partograph?

9
x
o
Mrs. A 3 2 567886
5/9/2014
5:00 a.m. 4:00 a.m.
CASE STUDY: Mrs. A
There are 3 contractions in 10 minutes, each lasting 20-
40 seconds
Fetal heart rate (FH) is 120
Membranes ruptured, amniotic fluid is clear
Skull bones separated, sutures easily felt
Blood pressure is 120/70
Temperature is 36.8 C
Pulse is 80 per minutes
Urine output is 200 ml, negative protein and acetone

What steps should be taken? What advice should we
give?
What do we expect to find at 1:00 pm?

9
x
o
Mrs. A 3 2+0 7886
12.5.2000
5:00 a.m. 4:00 a.m.
C
1
CASE STUDY: Mrs. A
Step 3
Plot the following information on the partograph:
09:30 a.m. FH 120, contractions 3/10 each 30 sec, Pulse 80
10:00 a.m. FH136, contractions 3/10 each 30 sec, Pulse 80
10:30 a.m. FH140, contractions 3/10 each 35 sec, Pulse 88
11:00 a.m. FH130, contractions 3/10 each 40 sec, Pulse 88, Temp
37
11:30 a.m. FH136, contractions 4/10 each 40 sec, Pulse 84, Head
is 2/5 up
12:00 pm FH140, contractions 4/10 each 40 sec, Pulse 88
12:30 pm FH130, contractions 4/10 each 45 sec, Pulse 88
1:00 pm FH140, contractions 4/10 each 45 sec, Pulse 90, Temp 37
CASE STUDY: Mrs. A
1:00 pm
Fetal head is 0/5 palpable above the pubic
bone
Cervix is fully dilated
Amniotic fluid clear
Skull bones separated, sutures easily felt
Blood pressure 100/70
Urine output 150 ml; negative protein and
acetone

What steps should be taken? What advice
should be given?
What do you expect to happen next?
9
x
o
Mrs. A
3 2
567886
5/9/2014 5:00 a.m. 5
C
1
10 11 12 1
o
x
CASE STUDY: Mrs. A

01:20 pm: spontaneous delivery of a live term female

CASE STUDY: Mrs. B
Step 1:
Mrs B. was admitted at 7:00 am on 3/7/2014
Gravida 1, para 0
Hospital number 679456
On admission, the fetal head was 3/5 palpable
above the pelvic bone and the cervix was 4 cm
dilated.

What should we record on the partograph?
7
x
o
Mrs. B
1 0
679456
3/7/2014 7:00 a.m.
I
0
CASE STUDY: Mrs. B
Step 2:

11:00 am
The fetal head is 1/5 palpable above the
pubic bone
The cervix is 5 cm dilated

What steps should be taken? What advice
should we give?

7
x
o
Mrs. B
1 0
679456
3/7/2014 7:00 a.m.
I
0
8 9 10 11
o
x
C
1
10
CASE STUDY: Mrs. B
Step 3:

13:00 am
The fetal head is 0/5 palpable above the
pubic bone
The cervix is 8 cm dilated

What steps should be taken? What advice
should we give?
7
x
o
Mrs. B
1 0
679456
3/7/2014 7:00 a.m.
I
0
8 9 10 11
o
x
C
1
x
10 10
o
C
1
12 13
CASE STUDY: Mrs. B
Step 4:

14:00 am
The fetal head is 0/5 palpable above the
pubic bone
The cervix is fully dilated

7
x
o
Mrs. B
1 0
679456
3/7/2014 7:00 a.m.
I
0
8 9 10 11
o
x
C
1
x
x
10 10
o o
C
C
1 1
C C C
C
1 1 1 1
12 13 14
CASE STUDY: Mrs. B

02:30 pm: spontaneous delivery of a live term male

CASE STUDY: Mrs. C
Step 1:
Mrs C. was admitted at 10:00 am on 3/14/2014
Gravida 1, para 0
Hospital number 567745
On admission, the fetal head was 4/5 palpable
above the pelvic bone and the cervix was 4 cm
dilated.
Her membranes ruptured at 5:00 am
FHT: 140
Contractions 3/10 each 30 sec

What should we record on the partograph?
10
x o
Mrs. C
1 0
567745
3/14/2014 10:00 a.m.
C
1
5
CASE STUDY: Mrs. C
Step 2:

2:00 pm
The fetal head is 1/5 palpable above the
pubic bone
The cervix is 5 cm dilated

What steps should be taken? What advice
should we give?

10
x
o
Mrs. C
1 0
567745
3/14/2014 10:00 a.m.
c
1
11 12 13 14
o
x
C
c c c c c c c
2
5
CASE STUDY: Mrs. C
Step 3:

5:00 pm
The fetal head is 0/5 palpable above the
pubic bone
The cervix is 5 cm dilated

What steps should be taken? What advice
should we give?
10
x
o
Mrs. C
1 0
567745
3/14/2014 10:00 a.m.
c
1
11 12 13 14
o
x
C
c c c c c c c
2
15 16 17
x
o
C B B B M M
3
5
CASE STUDY: Mrs. C

17:30 pm: Cesarean section of a live term male

Thank you