THE PARTOGRAPH

OBJECTIVES
I. To explain the concept of the WHO
partograph and its significance
 Mothers
 Members of the team of the health
care delivery network
II. To record the observations
accurately on the graph
III. To interpret the recorded findings,
recognize deviation from the norm,
and decide on timely referral
 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
FRIEDMAN’S CURVE
MONITORING DURING LABOR
• Progress of labor
• 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
THE PARTS OF THE PARTOGRAPH

Progress of labor

Maternal and fetal well-being

D
I
L Alert line
A
T
A
T
I
O
N
D
I
L Alert line Action line
A
T Parallel and
A 4 hours to
T the right
I of alert line
O
N
 CONDITIONS THAT NEED A
PARTOGRAPH
• All pregnant women in labor when
vaginal delivery is planned

*Use partograph
 CONDITIONS THAT DON’T
NEED A PARTOGRAPH
• Antepartum • Multiple
hemorrhage pregnancy
• Severe pre- • Malpresentation
eclampsia and • Very premature
eclampsia baby
• Fetal distress • Obvious
• Previous obstructed labor
cesarean section
 RECORDING THE FINDINGS
IN THE PARTOGRAPH

• Start by labeling the record

with pertinent patient
identifying information.
PLOTTING THE PROGRESS OF
LABOR ON THE GRAPH
• 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)
Start plotting on alert line in the
intersection corresponding
cervical dilatation finding
X
X
 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
 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
 X

X
4pm 8pm 10pm

Connect the “X”s to demonstrate

the pattern of labor
EXAMPLE

1am

A G1P0 is being monitored by a

midwife. Her initial IE at 1 am
showed 5 cm dilated cervix.
EXAMPLE
x

x
1am 5am

At 5 am, another IE showed 9

cm dilated cervix.
EXAMPLE
x
x

x
1am 5am 7am

At 7 am, the patient is 10 cm

dilated, intact BOW.
DISTINGUISHING NORMAL
FROM ABNORMAL LABOR
PATTERN
 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)
 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.
 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
WHEN PLOTTING PASSES THE
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
PLOTTING PASSES THE ACTION
LINE
• The patient must already be in a
CEmONC facility
• A decision must be made about
the cause of slow progress of labor
• Appropriate action must be taken
 Progress of labor

Maternal and fetal well-being

 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
 OTHER FINDINGS TO NOTE
AND RECORD EVERY 4 HOURS*
• Blood Pressure
• Pulse rate
• Temperature
• Urine voided (yes or no)
*More frequently, if indicated
MONITOR MORE FREQUENTLY
AND RECORD
• Number of contractions in 10
minute period
• Fetal heart rate in 1 full minute
 SPECIAL CASES

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.
 EXERCISES

• Indicate whether the progress of

labor in the following partographs
are normal or abnormal.
 x
Case 1

10pm 2am
Case 2

X X
X

12mn 2am 4am

X
8pm
Case 3
X X

9pm 1am 3am

 EXERCISES

• Plot the observations in the

following cases.
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.
 X
Maria, G1P0 X
Date Today X

X
2am 6am 8am

0 0
I C
3
140 140

88 88
110/70 110/70

8:35
8:30
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
Lourdes, G4P2
Date Today X

X
5pm 9pm 1am

M
3 3

36.5 36.5 37.5

80 80 92
120/80 120/80 110/70
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
Marites, G1P0
Date Today X X
X

X
6pm 10pm 12am 2am
2

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
 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
 E.F.M.
(ELECTRONIC
FETAL
MONITORING)
 E. F. M.
-Electronic monitoring is noninvasive, easily applied,
and does not require cervical
dilatation or fetal descent before it can be used, so
it can be introduced at any time
during labor.

Two devices (a transducer for the uterus and an

ultrasound sensor for the fetus) are
strapped to the woman’s abdomen
 USES
*nonstress test - a procedure that measures the fetal
heart rate in response to fetal movements
 USES
*contraction stress test - a procedure in
which the fetal heart rate is observed with
uterine contractions which have been
stimulated with medication or other
methods
 USES
*a biophysical profile, or BPP - a test that combines a
nonstress test with ultrasound
 E. F. M
REASONS FOR THE PROCEDURE:

assess fetal well-being and identify any changes that

might be associated with problems during pregnancy
or labor
 PROCEDURE
1. Check the doctor’s order
2. Identify patient
3. Explain the procedure to the patient. Instruct her to remain in a
fairly fixed position for 20minutes. Keep her well informed of the
importance and purpose of the test and be certain she
understand the meaning of the results after the test
4. Instruct her to void before the procedure and change clothes
to a hospital gown
5. Assist her to lie on the examination table/bed with the
abdomen exposed
6. A clear gel will be applied to your abdomen (the gel acts as a
conductor).
 PROCEDURE
7. The transducer will be pressed against the
skin and moved around until the fetal
heartbeat is located. A wide elastic belt will
be placed around the pt’s back to secure
the transducer in place..

8. With continuous electronic monitoring, the

fetal heart pattern will be displayed on a
computer screen and printed onto graph
paper.

9. Once the procedure has been

completed, the transducer will be removed
and the gel will be wiped off.
RHYTHM STRIP
 INTERPRETATIONS

BASELINE FHR- determined by analyzing

the pace of fetal heartbeats recorded
in a
minimum of 2 minutes obtained
between contractions

Normal: 110-160 bpm

 VARIABILITY

-the difference between the highest and lowest heart rates shown on a
strip is one of the most reliable indicators of fetal well-being

- A normal irregular changes or fluctuations in the FHR

- Variability should be recorded as:

- Absent: No amplitude range is detectable.

- Minimal: Amplitude range is detectable but is 5 beats/min or fewer.
- Moderate (normal): Amplitude range is 6 to 25 beats/min.
- Marked: Amplitude range is greater than 25 beats/min.
 ACCELERATIONS
Nonperiodic accelerations are temporary
normal increases in FHR caused by fetal
movement, a change in maternal position,
or administration of an analgesic
 DECELERATIONS

- are visually apparent, usually symmetrical, periodic

decreases in FHR
resulting from pressure on the fetal head during
contractions as parasympathetic
stimulation in response to vagal nerve compression
brings about a slowing of FHR
 EARLY DECELERATIONS

- follows the pattern of the contraction starting

when the contraction begins and ending when
the contraction subsides.
- resulting from pressure on the fetal head during
contractions
- Normal
 LATE DECELERATIONS

- Late decelerations are those in which the onset, nadir,

and recovery of the deceleration
occur after the beginning, peak, and ending of the
contraction, respectively
- it suggests uteroplacental insufficiency or
decreased blood flow through the intervillous spaces of
the uterus during uterine contractions
- Not normal
● The partograph is designed for recording
maternal identification, fetal heart rate, colour
of the amniotic fluid, moulding of the fetal skull,
cervical dilatation, fetal descent, uterine
contractions, whether oxytocin was
administered or intravenous fluids were given,
maternal vital signs and urine output.
 PROLONGED
DECELERATIONS
- decelerations that are a decrease from the FHR
baseline of
15 beats/min or more and last longer than 2 to 3
minutes but less than 10 minutes

- cord compression or maternal hypotension