PARTOGRAPH

Made Easy

Source : Basic Emergency Obstetric Care Dr. Jose Fabella Memorial Hospital, & WHO

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

OBJECTIVES
I. To understand the concept of the WHO partograph To explain to mothers the significance of the graph 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

Monitor 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 A T A T I O N

Alert line

D I L A T A T I O N

Alert line

Action line

Parallel and 4 hours to the right of alert line

Conditions that does 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

II. Recording the findings in the partograph

Start by labeling the record with pertinent patient identifying information.

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)

Start plotting on alert line in the intersection corresponding cervical dilatation finding

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 Xs to demonstrate the pattern of labor

EXAMPLE

x 1am A G1P0 is being monitored by a midwife at home. Her initial IE at 1 am showed 4 cm dilated cervix.

EXAMPLE
x

x 1am 5am

At 5 am, another IE showed 8 cm dilated cervix.

EXAMPLE
x

x 1am 5am 7am

At 7 am, the patient is 9 cm dilated, station -1, intact BOW.

III. Distinguishing normal fromabnormal labor pattern

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

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

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

What to do if partograph passes alert line

Reassess woman and consider criteria for referral. Alert transport services. Empty bladder. Ensure adequate hydration but omit solid foods. Encourage upright position and walking if woman wishes. Monitor intensively. If referral long, reassess in 2 hours and refer if no progress. If partograph passes action line, refer urgently to an EmOC facility unless imminent delivery.

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

THE PARTS OF THE PARTOGRAPH

Progress of labor

Maternal and fetal well-being

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

Monitor every 4 hours* and record the findings

Blood Pressure Pulse rate Temperature Urine voided (yes or no)
* More frequently, if indicated

Monitor more frequently and record the findings

Number of contractions in 10 minute period Fetal heart rate in 1 full minute

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

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

Case 1

10pm

2am

Case 2
X X
8pm

12mn

2am

4am

Case 3

X X

9pm

1am

3am

EXERCISES
Plot the observations in the following cases.

Case 4:
A G2P1 was admitted at 2 am, IE showed a 4cm dilated cervix. The patient was still smiling and she was hesitant to be admitted. At 6 am, another IE was done 8 cm dilated cervix, 80% effaced, station 0. At 8 am, fetal head was bulging at the perineum.

Answer to case 4

X X

2am

6am

8am

Case 5:
A G4P2 was referred at 5 pm. The midwife said that the patient is at 4 cm cervical dilatation. At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, 50% effaced, station -1, intact BOW.

Answer to case 5
X

5pm

9pm

1am

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