PARTOGRAPH

Slide 2

 WHAT IS PARTOGRAPH??
 A partograph is a graphical record of the observations made of a women in labour
 For progress of labour and salient conditions of the mother and fetus
 It was developed and extensively tested by the world health organization WHO

Slide 3

History Of Partogram
Friedman's partogram devised in 1954 was based on observations of cervical dilatation and foetal station against time
elapsed in hours from onset of labour. The time onset of labour was based on the patient's subjective perception of her
contractility. Plotting cervical dilatation against time yielded the typical sigmoid or 'S' shaped curve and station against
time gave rise to the hyperbolic curve.
Limits of normal were defined

Slide 4

WHO partograph:
Overview
 The partograph can be used by health workers with adequate training in midwifery who are able to :
 observe and conduct normal labour and delivery.
 Perform vaginal examination in labour and assess cervical diltation accurately
 plot cervical diltation accurately on a graph against time
 There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery
 Whether used in health centers or in hospitals , the partograph must be accompanied by a program of training in its
use and by appropriate supervision and follow up.

Slide 5

Objectives
 Early detection of abnormal progress of a labour prevention of prolonged labour
 Recognize cephalopelvic disproportion long before obstructed labour
 Assist in early decision on transfer , augmentation , or terminjation of labour
 Increase the quality and regularity of all observations of mother and fetus
 Early recognition of maternal or fetal problems
 The partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum
hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc.).

Slide 6
Partograph function
 The partograph is designed for use in all maternity settings , but has a different level of function at different levels of
health care in health center, the partograph/s critical function is to give early warning if labour is likely to be prolonged
and to indicate that the woman should be transferred to hospital (ALERT LINE FUNCTION )
 In hospital settings, moving to the right of alert line serves as a warning for extra vigilance , but the action line is the
critical point at which specific management decisions must be made other observations on the progress of labour are
also recorded on the partograph and are essential features in management of labour.
Slide 7

Components of the partograph

 Part 1 : fetal condition ( at top )

 Pqrt 11 : progress of labour ( at middle )
 Part 111 : maternal condition ( at bottom )
 Outcome : ………………

Slide 8

Part 1 : Fetal condition

 This part of the graph is used to monitor and assess fetal condition
 1 - Fetal heart rate
 - membranes and liquor
 - moulding the fetal skull bones Caput

Slide 9

Fetal heart
rate
Basal fetal
heart rate
 < 160 beats/mi =tachycardia
 > 120 beats/min = bradycardia
 >100 beats/min = severe bradycardia

Decelerations? yes/no
Relation to contractions?
- Early
- Variable
- Late –-----Auscultation - return to baseline
> 30 sec contraction
----Electronic monitoring peak and trough (nadir)
> 30 sec
Slide 10

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
Slide 11

Moulding 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 ( reducible 0 ……………………...++
 severely overlapping bones ( non – reducible ) ……..+++

Slide 12

Part 2 : progress of labour

 Cervical Dilation:
 Descent of the fetal head
 Fetal position
 Uterine contractions
 this section of the paragraph has as its central feature a graph of cervical diltation against time
 it is divided into a latent phase and an active phase


Slide 13

:latent phase
 it starts from onset of labour until the cervix reaches 3 cm diltation
 once 3 cm diltation is reached , labour enters the active phase
 lasts 8 hours or less
 each lasting <20 sceonds
 at least 2/10 min contractions
Slide 14

:Active phase
 Contractions at least 3 / 10 min
 each lasting < 40 sceonds
 The cervix should dilate at a rate of 1 cm / hour or faster

Slide 15

:Alert line ( health facility line)

 The alert line drawn from 3 cm diltation represents the rate of diltation of 1 cm / hour
 Moving to the right or the alert line means referral to hospital for extra vigilance

Slide 16

:Action line (hospital line)

 The action line is drawn 4 hour to the right of the alert line and parallel to it
 This is the critical line at which specific management decisions must be made at the hospital

Slide 17

Cervical diltation
 It is the most important information and the surest way to assess progress of labour , even though
other findings discovered on vaginal examination are also important
 when progress of labour is normal and satisfactory , plotting of cervical diltation remains on the
alert line or to left of it
 if a woman arrives in the active phase of labour , recording of cervical diltation starts on the alert
line
 when the active phase of labor begins , all recordings are transferred and start by pltting cervical
diltation on the alert line

Slide 18

Slide 19

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

Slide 20

Slide 21

Assessing descent of the fetal head by

vaginal examination;
0 station is at the level of the ischial spin

Slide 22

Fetal position
Occiput transverse positions

Occiput anterior positions

Slide 23

Uterine contractions
 Observations of the contractions are made every hour in the latent phase and every half-hour in the
active phase frequency how often are they felt ?
 Assessed by number of contractions in a 10 minutes period duration how long do they last ?
 Measured in seconds from the time the contraction is first felt abdominally , to the time the contraction
phases off
 Each square represents one contraction

Slide 24

Palpate number of contraction in ten minutes and duration of each contraction in seconds

 Less than 20 seconds:


 Between 20 and 40 seconds:

 More than 40 seconds:

Slide 25

Part 3 :maternal condition

Name / DOB /Gestation Medical / Obstetrical issues
Assess maternal condition regularly by monitoring :
 drugs , IV fluids , and oxytocin , if labour is augmented pulse , blood pressure
 Temperature
 Urine volume , analysis for protein and acetone
Slide 26

Slide 27

Management of labour using partograph

Slide 28

 latant phase is less than 8 hours

 progress in active phase remains
on or left of the alert line
 Do not augment with oxytocin if latent and active phases go normally
 Do not intervene unless complications develop
 Artificial rupture of membranes ( ARM )
 No ARM in latent phase
 ARM at any time in active phase

Slide 29

Slide 30

Between alert and action lines

 In health center , the women must be transferred to a hospital with facilities for cesarean section ,
unless the cervix is almost fully dilated
 Observe labor progress for short period before transfer Continue routine observations
 ARM may be performed if membranes are still intact

Slide 31

At or beyond action line

Conduct full medical assessement
Consider intravenous infusion / bladder catheterization / analgesia Options
 Deliver by cesarean section if there is fetal distress or obstructed labour
 Augment with oxytocin by intravenous infusion if there are no contraindications
Slide 32

ABNORMAL PROGRESS OF LABOR

Slide 33

 One of the main functions of the partograph is to detect early deviation from normal progress of labor

Slide 34

Moving to the right of alert line

 This means warning
 Transfer the woman from health center to hospital reaching the action line
 This means possible danger
 Decision needed on future management (usually by obesteritian or resident )

Slide 35

Prolonged latent phase

 If a woman is admitted in labor in the latent phase ( less than 3 cm diltation ) and remains in the
latent phase for next 8 hours
 Progress is abnormal and she must br transferred to a hospital for a decision about further action
 This is why there is a heavy line drawn on the partograph at the end of 8 hours of the latent phase

Slide 36
Prolonged Active phase
 In the active phase of labor , plotting of
cervical diltation will normally remain
on or to the left of the alert line
 But some cases will move to the right of
the alert line and this warns that labor
may be prolonged
 This will happen if the rate of cervical
diltation in the active phase of labor is
not 1 cm / hour or faster
 A woman whose cervical diltation moves to
the right of the alert line must be
transferred and manged in a hospital with
adequate facilities for obstetric
intervention unless delivery is near at
the action line , the woman must be
carefully reassessed for why labor is not
progressing and a decision made on
further management
Slide 37

Slide 38

Secondary arrest of cervical diltation

 Abnormal progress of labor may occur in cases with normal progress of cervical diltation then
followed by secondary arrest of diltation
Slide 39

Slide 40

Secondary arrest of head descant

 Abnormal progress of labor may occur with normal progress of descent of the fetal head then followed
by secondary arrest of desscent of fetal head
Slide 41

Precipitate Labour
- Maximum slope of dilatation of 5 cm/hr or more
Slide 42

USING THE PARTOGRAPH POINTS TO REMEMBER

Slide 43

1. It is important to realize that the partograph is a tool for managing labor progress only
2. The partograph does not help to identify other risk factors that may have been present before labor started
3. Only start a partograph when you have checked that there are no complications of pregnancy that require immediate
action
4. A partograph chart must only be started when a woman is in labor,-- be sure that she is contracting enough to start a
partograph
5. If progress of labor is satisfactory , the plotting of cervical diltation will remain or to the left of the alert line

Slide 44

6. When labor progress well , the diltation should not move to the right of the alert line
7. The latent phase . 0 – 3cm diltation , is accompanied by gradual shortening of cervix . normally , the latent phase should
not last more than 8 hours
8. The active phase , 3 – 10 cm diltation , should progress at rate of least 1 cm/hour
9. When admission takes place in the active phase , the admission diltation, is immediately plotted on the alert line

Slide 45

10. when labor goes from latent to active phase , plotting of the diltation is immediately transferred from the latent phase
area to the alert line
Slide 46

11. diltation of the cervix is plotted ( recorded with an X , desent of the fetal head is plotted with
an O , and uterine contractions are plotted with differential shading
12. desent 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
13. assessing descent of the head assists in detecting progress of labor
increased molding with a high head is a sign of cephalopelvic disproportion
14. increased molding with a high head is a sign of cephalopelvic disproportion

Slide 47

15. vaginal examination should be performed infrequently as this is compatible with safe practice ( once
every 4 hours is recommended )
16. when the woman arrives in the latent phase , time of admission is 0 time
17. a woman whose cervical diltation moves to the right of the alert line must be transferred and manged
in an institution with adequate facilities for obstetric intervention , unless delivery is near.
18. 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 )

Slide 48

19. 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,
20. Leaving the area between the transferred recording blank. The broken transfer line is not part of the
process of labor
21. do not forget to transfer all other findings vertically

Slide 49

IMPORTANT COSIDERATIONS
Slide 50

OXYTOCIN

 Oxytocins must be preserved in a cool , dark place

 A local regime may be used 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
 It may br maintained at the rate thoughout the second stage of labor
 Stop oxytocin infusion if there is evidence of uterine hyperactivity and / or fetal distress
 Oxytocin must be used with caution in multiparous women and rarely , if at all , in women of para 4 or more
 Augment with oxytocin only after artificial rupture of membranes and provided that the liquor is clear
Slide 51

MEMBRANES
 if membranes have been ruptured for 12 hours or more , antibiotics should be given
 As a first defense against serious infections, give a combination of antibiotics:
 ampicillin 2 g IV every 6 hours;
 PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
 PLUS metronidazole 500 mg IV every 8 hours.
 Note:
 If the infection is not severe, amoxicillin 500 mg by mouth every 8 hours can be used instead of
ampicillin. Metronidazole can be given by mouth instead of IV.

Slide 52

FETAL DISTRESS
 If a woman is laboring in a health center . transfer her to a hospital with facilities for operative
delivery
 In a hospital , immediately :
 Conduct a vaginal examination to exclude cord prolapse and observe amniotic fluid
 Provide adequate hydraion
 Administer oxygen , if avaliablestop oxytocin
 -Turn the woman or her left side
Slide 53

Diagnosis of labour
Regular painful contractions resulting in progressive change of the cervix

+/- show
+/- rupture of membranes
Slide 54

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