partograph bo

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 rate2. membranes and liquor3. 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 dilatationAction 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 minutesNumber/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 labourPatient pain , bladder empty , dehydration , exhaustionPowers Uterine contractions Maternal effortPassages Maternal pelvis ( Inlet - Outlet ) Maternal soft tissuePassenger 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. AStep 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. AStep 2:

09:00 am• The fetal head is 3/5 palpable above the

pubic bone• The cervix is 5 cm dilated


9

x

o

Mrs. A 3 2 5678865/9/2014 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 788612.5.2000 5:00 a.m. 4:00 a.m.

C1

CASE STUDY: Mrs. AStep 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. A1:00 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

C1

10 11 12 1

o

x

CASE STUDY: Mrs. A

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

CASE STUDY: Mrs. BStep 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.


7

x o

Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I0

CASE STUDY: Mrs. B Step 2:



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.

I0

8 9 10 11

o

x

C1

10

7

x o

Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I0

8 9 10 11

o

x

C1

x

1010

o

C1

12 13



pubic bone• The cervix is fully dilated

7

x o

Mrs. B 1 0 679456

3/7/2014 7:00 a.m.

I0

8 9 10 11

o

x

C1

x

x

1010

o o

C C1 1

C CC C1 1 1 1

12 13 14

CASE STUDY: Mrs. B

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

CASE STUDY: Mrs. CStep 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


10

x o

Mrs. C 1 0 567745

3/14/2014 10:00 a.m.

C1

5

CASE STUDY: Mrs. C Step 2:

2:00 pm• The fetal head is 1/5 palpable above the



10

x o

Mrs. C 1 0 567745

3/14/2014 10:00 a.m.

c1

11 12 13 14

o

x

Cc c c c c c c2

5

CASE STUDY: Mrs. C Step 3:

5:00 pm• The fetal head is 0/5 palpable above the



10

x o

Mrs. C 1 0 567745

3/14/2014 10:00 a.m.

c1

11 12 13 14

o

x

Cc c c c c c c2

15 16 17

x

o

C B B B M M3

5

CASE STUDY: Mrs. C

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

Thank you

partograph bo

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