partograph gynecology medical lecture for students

Medical lecture in gynecology and obstetrics

1. Partograph
Shahad Alkhursan

2. - The partograph is a graphical presentation of the progress of labour, and of fetal and maternal
condition during labour. It is the best tool to help you detect whether labour is progressing normally
or abnormally, and to warn you as soon as possible if there are signs of fetal distress or if the
mother's vital signs deviate from the normal range.
- You need to monitor a labouring mother carefully. Remember that a labour that is progressing well
requires your help less than a labour that is progressing abnormally. Documenting your findings on
the partograph during the labour enables you to know quickly if something is going wrong, and
whether you should refer the mother to the nearest higher health facility or hospital for further
evaluation and intervention.
- Write the name and age of the mother, her 'gravida' (number of pregnancy regardless the outcomes,
the current pregnancy should be included ) and 'para' (number of births after 24. Weeks of gestation
including alive or dead fetus) status, her health facility or hospital registration number, the date and
time when you first attended her for the delivery, and the time the fetal membranes ruptured (her
'waters broke'). Partograph:

3. Recording cervical dilatation and fetal decent :
- We start recording partograph only when the cervical dilatation reaches 4cm !!- Cervical dilatation is assessed every vaginal examination (every four hours) and marked with X
The first plot (or mark) should
always be on the alert line
so If a woman presented with
6cm of dilatation, the first plot
should be here
The alert line start
from 4cm to 10cm at
rate of 1cm per hour
You can't put it here
As the example above
the woman presented
with 4cm of dilatation
this mean that at the
first hour of recording
the dilatation was 4cm
The Action line:
parallel and 4 hours
to the right of the
alert line. In normal
labor we should never
reach the action line
Although we said that we should start
partograph at 4cm of dilatation but
sometimes the women come to the
hospital and she is already with 6cm
dilatation so we can't start or plot at
4cm point and we plot in 6cm
Typically if the woman
presented to us with
4cm we will plot here
And we should record the
time at which we found
the 4cm dilatation
4:oo
a.m
We said that the cervical
dilatation should be in a ratio of
1cm dilatation per one hour so
that we can plot on the alert
line, which means at the first it
was 4cm and then we
preformed vaginal exam after
one hour we should find that
the cervical dilatation became
5cm (usually vaginal exam is
preformed every hours not
every one hour so if we
preformed it after 4hours we
should find that the cervical
dilatation became 7cm)
If the cervical dilatation was
slow i.e: even after 6 hours the
vaginal dilatation is 5cm (normal
it should be 9cm) we will reach
the action line
When dilatation
reaches 10cm fetus
could be delivered
If you found that some Xs are not on the alert line
(before it) this mean that the dilatations are more than
1cm per hour (it's common to find this) and the woman
will reach 10cm and deliver before 7 hours of labor 7:oo
a.m

4. fetal descent :
- We assess the descent of the head by #abdominal palpation
- we divide the head into five fifths, and feel how many fifths are palpable above the pubic symphysis
- it is recorded as a small O at the same time as every vaginal exam. (As we record the cervical
dilatation we should preform abdominal palpation to record the fetal descent at this stage of
dilatation)
- if you palpate 5 fifths the mean that the fetal head is not engaged or descent (5)
- if you didn't find any fifth to palpate this means that the fetus has fully descended or engaged (0)
- We record the cervical dilatation and the descent at the same time because they are related to each
other (if there is speculation dilatation there should be descent that is proportional to this dilatation) but if
we found that there is adequate dilatation but the head is not fully descended this mean that either the
baby is too large or the pelvis is too small which both prevent descent and engagement of the head

5. - example: woman presented with 5cm cervical dilatation we preformed abdominal palpation and
we found that 3 fifths of the fetal head are palpable after 2 hours the vaginal exam. Revealed
7cm dilatation and abdominal palpation we found that 2 fifths are palpable
Now in order to record
we said that we should
record the descent at
the same time of the
dilatation so we should
plot the 5cm dilatation
as X then at the
#same axis we plot the
descent as an O
After 2 hours the dilatation was
7cm and descent was 2

6. Fetal heart rate :
- The fetal heart rate is recorded at the top of the partograph every 30 min in the first stage of labour (if
every count is within the normal range), and every 5 minutes in the second stage
- Count every five minutes if the amniotic fluid (called liquor on the partograph) contains thick green or black
meconium.
- Whenever the fetal membranes rupture, you should count the heart rate because occasionally there may be
cord prolapse and compression, or placental abruption as the amniotic fluid gushes out.
- The normal fetal heart rate at term (37 weeks and more) is in the range of 120–160 beats/minute
Each square for the
fetal heart on the
partograph represents
30 minutes.
At first 30 min
HR was 120
After 30 min
HR became 130
After another 30
min HR was 120

7. Amniotic fluid:
- Record the state of amniotic at each vaginal examination
- If the membrane is still intact mark (I) if the membrane is ruptured you can mark with (R)
- If the membrane is ruptured you should notice the color of the amniotic fluid, if it was clear
mark (C) if it was meconium stained mark (M), if it was blood stained mark (B) and if the
amniotic fluid is absent mark (A).
The membrane is intact
The membrane
has ruptured and
the fluid is clear
You should record at which time
the membrane ruptured above
on the partograph paper
The fluid became
meconium stained

8. - The five separate bones of the fetal skull are joined together by sutures, which
are quite flexible during the birth, and there are also two larger soft areas called
fontanels. Movement in the sutures and fontanels allows the skull bones to overlap
each other to some extent as the head is forced down the birth canal by the
contractions of the uterus. The extent of overlapping of fetal skull bones is called
moulding, and it can produce a pointed or flattened shape to the baby's head when
it is born
- Whenever you detect moulding in the fetal skull as the baby is moving down the birth canal, you
have to be more careful in evaluating the mother for possible disproportion between her pelvic opening
and the size of the baby's head. Make sure that the pelvic opening is large enough for the baby to
pass through. A small pelvis is a frequent cause of prolonged and obstructed labour.
moulding:

9. First palpate the suture lines on the fetal head and appreciate whether the following conditions apply.
The skull bones that are most likely to overlap are the parietal bones, which are joined by the sagittal
suture, and have the anterior and posterior fontanels to the front and back.
-If the bones are separated and the sutures can be felt easily, degree 0.
-If sutures apposed: This is when adjacent skull bones are touching each other, but are not overlapping.
This is called degree 1 moulding (+1).
-If sutures overlapped but reducible: This is when you feel that one skull bone is overlapping another,
but when you gently push the overlapped bone it goes back easily. This is called degree 2 moulding (+2).
- If sutures overlapped and not reducible: This is when you feel that one skull bone is overlapping
another, but when you try to push the overlapped bone, it does not go back. This is called degree 3
moulding (+3) the baby should be delivered at this degree.
If you find +3 moulding with poor progress of labour (there is no or small head descent), this may
indicate that the labour is at increased risk of becoming obstructed.
To identify moulding:

10. Each one column
represents 10 minutes
10min
10min
10min
And each box in the same column
represents one contraction at this
10min (maximum number of
contractions in 10min is 5 contractions
thus we have 5 boxes in each column
First
contraction
in 10min
Second Third
Fourth
Fifth
Dots represent mild
contraction that last
less than 20 sec
Diagonal lines indicate
moderate contraction
20-40
Solid shading represents
strong contraction that
last longer than 40 sec
- good uterine contractions are necessary for good progress of labour.
- Normally, contractions become more frequent and last longer as labour progresses.
-Contractions are recorded every 30 minutes on the partograph in their own section, which is below the hour/time rows.
- At the left hand side is written 'Contractions per 10 mins' and the scale is numbered from 1–5.
- Each square represents one contraction, so that if two contractions are felt in 10 minutes, you should shade two
squares.
- On each shaded square, you will also indicate the duration of each contraction by using the symbols shown in the Figure
below.
When you want to interpret this column:
you say that there is four strong
contraction in the past 10 min
Uterine contractions:

11. - If there was administration of Oxytocin during labour you should record the amount of oxytocin and
the amount of iv fluid that it has been added to
- Also record drugs and iv fluid that has been given to the patient during labor

12. Maternal vital signs:
- Blood pressure is measured every four hours, marked with ( )
- Pulse is recorded every 30 minutes marked with ( )
Systolic Diastolic
Each column
represents 30
minutes
30min
30min
30min
The pulse was 80, after 30 min it became 90,
and after another 30min it returned to 80, ........
The BP was 110/70 and after
four hours it was still 110/70

13. - Temperature is recorded every 2 hours.
- Urine output is recorded every time urine is passed, and test if it contains
proteins or acetone (normally it doesn't also record the volume of the urine
37
37
200ml
NilNil

14. If the woman
presented with 5cm
pf dilatation we plot
X on the alert line
All other observations will
be plotted at the same axis
or after the axis that is
indicated by the centimeters
of dilatation at presentation
You can't record any thing
after this time or axis

17. 1- FATIMA
FATIMA is admitted to the hospital at 24 h of labor on admission the cervix is 5cm
dilated and the fetal head is 3 fifths palpable, all other observations are normal.
After three hours of labor, the fetal heart rate, maternal pulse and BP remains
normal
Case studies:
The cervix is now 8cm dilated and the fetal head is 1 fifth palpable
What action should be taken??
No action, labor is progressing normally, the observations indicates that no
interventions are required because we didn't reach the action line

18. 2- Mariam
Mariam is admitted with 4cm cervical dilatation, the baby's head has descended
fully in the pelvis (no fifth is palpable)
After four hours of labor the cervix had only dilated 1cm, the amniotic membrane
had ruptured and the fluid is clear, the head remains 0 fifth palpable, also we
notice that the contractions are mild
What action should be taken??
The observations suggest that Mariam is experiencing prolonged labor so
oxytocin should be administered and recoded at the partograph with
other observations

19. 3- YASMIN
YASMIN is admitted at 19:30 and after vaginal exam. There was 4cm of
cervical dilatation and the fetal head is not engaged (5 fifths are palpable)
the amniotic membrane is still intact
After four hours of labor her cervix was 8cm dilated but the fetal
head still 5 fifths palpable.
The membrane had ruptured and the fluid is clear.
By 8 hours of active labor, she is still 8cm dilated and the baby's head is still
not engaged

20. The amniotic fluid became meconium stained and the frontal bones of the
fetal scalp are severely overlapped
And her BP is increasing.
What action should be taken??
The observations suggest that the baby is not descending and that the
labor maybe obstructive, her cervical dilatation and fetal descent had
crossed the alert time and she probably will need a delivery by cesarean
section.