The partograph

A Partograph is a graphical record of progress during labor.
Progress is measured by cervical dilatation against time in hours, as well as by providing a record of the important conditions of the mother and fetus that may arise during the process

1. THE PARTOGRAPH
By
Dr. Maraey M. Khalil,MBBCh, MSc, MD
lecturer and consultant in Obstetrics and Gynaecology,
Aswan University, Egypt

2. EmanuelA.Friedmanprovideafoundationbasis
fordevelopmentofpartographonthebasisof
observationoflargenumberofwomaninlabour.
•Afterthat,thecompositepictureoflabourwas
reportedbyPhilpottin1972,whocombineddetails
ofprogressoflabourtogetherwithinformation
aboutfetalandmaternalconditions.
History

3. Emanuel A. Friedman Professor of Obstetrics, Gynecology, and Reproductive
Biology at Harvard Medical School

4. •Definition
•APartographisagraphicalrecordofprogressduring
labor.
•Progressismeasuredbycervicaldilatationagainst
timeinhours,aswellasbyprovidingarecordofthe
importantconditionsofthemotherandfetusthatmay
ariseduringtheprocess.

5. PURPOSE OF THE PARTOGRAPH
•To detect abnormal progress of labor as early as possible.
•To prevent prolonged labor.
•To recognize cephalopelvic disproportion long before
obstructed labor.
•To assist in early decision on augmentation or termination
of labor.
•To increase the quality and regularity of all observations of
mother and fetus.
•To recognize maternal or fetal problems as early as
possible.

6. COMPONENTS OF THE
PARTOGRAPH
Part I:Assessment of fetal condition.
Part II:Progress of Labor.
Part III:Assessment of maternal condition.
Part IV:Outcome of labor.

8. PART I: ASSESSMENT OF FETAL
CONDITION
•Fetal Heart Rate
•> 160 beats/min = Tachycardia
•<120 beats/min = Bradycardia
•<100 beats/min = Severe bradycardia

10. MEMBRANES AND LIQUOR
•Plotting of the condition of the membranes and liquor
in the Partograph is as follows:
•Intact membranes I
•RM + Clear liquor C
•RM + Meconium-stained liquorM
•RM + Blood-stained liquor B
•RM + Absent liquor A

12. MOLDING OF THE FETAL
SKULL BONES
•Molding is an important indication of how adequately the
pelvis can accommodate the fetal head. It is plotted as
follows:
•Separated bones, sutures felt easily0
•Bones just touching each other+
•Overlapping bones (reducible)++
•Severely overlapping bones+++
Note: Increasing molding with the head high in the pelvis
is an ominous sign of cephalopelvic disproportion.

14. PART II: PROGRESS OF LABOR
Cervical Dilatation
•Latent Phase
•Starts from onset of labor until the cervix reaches 3 cm dilatation.
•Lasts eight hours or less.
•Contractions occur at least twice every 10 minutes with each
lasting >20 seconds.
•Active Phase
•Starts when the cervix reaches 3 cm dilatation.
•Contractions occur three times every 10 minutes with each lasting
>40 seconds.
•The cervix should dilate at a rate of 1 cm/hour or faster.

16. •Alert Line (Health Facility Line)
The Alert Line drawn from 3 cm to 10 cm dilatation
represents the rate of dilatation of 1 cm/hour.
•Action Line (Hospital Line)
The Action Line is drawn four hours to the right of
the Alert Line and parallel to it. This is the critical line
at which specific management decisions must be made.

17. DESCENT OF FETAL HEAD
•Adominalexaminationimmediatelybeforedoingavaginal
examination,usingtheruleofFifthstoassessengagement.
•TheRuleofFifthsmeansthepalpablefifthsofthefetalhead
thatarefeltbyabdominalexaminationabovethelevelof
symphysispubis.
•When2/5orlessofthefetalheadarefeltabovethelevelof
thesymphysispubis,thismeansthattheheadisengaged,
andbyvaginalexamination,thelowestpartofvertexhas
passedorisattheleveloftheischialspines.

22. UTERINE CONTRACTIONS
•Frequency
•How often are they felt?
•Frequency of contractions is assessed by the number
of contractions in a 10-minute 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.

25. PART III: MATERNAL CONDITION
•Pulse every 30 minutes.
•Blood pressure every 4 hours.
•Temperature every 2 hours.
•Urine volume, analysis for protein and acetone.
•Drugs, IV Fluids

27. POINTS TO REMEMBER WHEN
USING THE PARTOGRAPH:
•ThePartographdoesnothelptoidentifyotherriskfactorsthat
mayhavebeenpresentbeforelaborstartede.g.medical
conditions.
•APartographchartmustonlybestartedwhenawomanisin
labor.
•Ifprogressoflaborissatisfactory,theplottingofcervical
dilatationwillremainonortotheleftoftheAlertLine.
•Dilatationofthecervixisplotted(recorded)withanX,descent
ofthefetalheadisplottedwithanO,anduterinecontractions
areplottedwithdifferentialshading.

28. •When admission takes place in the active phase the cervical dilatation at admission is
immediately plotted on the Alert Line.
•Descent of the head should always be assessed by abdominal examination (by Rule of
Fifths felt above the pelvic brim) immediately before doing a vaginal examination.
•When the woman arrives in the latent phase the time of admission is 0 time.
•When a woman in labor passes the latent phase in less than eight hours, i.e., transfers
from latent to active phase, the most important feature is to transfer plotting of cervical
dilatation to the Alert Line using the letters TR, leaving the area between the transferred
recording blank. The broken transfer line is not part of the process of labor.
•Do not forget to transfer all other findings vertically.
POINTS TO REMEMBER WHEN
USING THE PARTOGRAPH:

30. MANAGEMENT OF LABOUR
USING THE PARTOGRAPH

31. LATENT 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 interfere unless complications
develop
•No ARM in latent phase
•ARM at any time in active phase

32. 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.

33. AT OR BEYOND ACTION LINE
•Conduct full medical assessment
•Consider intravenous infusion / bladder catheterization /
analgesia
•Options:
1-Deliver by cesarean section if there is fetal distress or
obstructed labour.
2-Augment with oxytocin by intravenous infusion if there
are no contraindications.

34. ABNORMAL PROGRESS OF LABOR

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

36. CLINICAL TYPES
First stage
•Protracted latent phase
•Protracted or arrest of active phase
Protracted second stage
Precipitate labour

37. PROLONGED LATENT PHASE
•> 20hrs in primigravida , >14hrs in
multigravida
•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 be
transferred to a hospital for a decision
about further action
•This is why there is alert line drawn on
the partograph at the end of 8 hours of
the latent phase

38. CAUSES OF PROLONGED LATENT PHASE
•False labour pain
•Atony or over sedation
•CPD
•Thick uneffaced cervix

39. PROLONGED (PROTRACTED) ACTIVE PHASE
•In the active phase of labor , plotting of
cervical dilatation 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
dilatation in the active phase of labor is
not 1 cm / hour or faster
•Causes:
1.Malposition
2.CPD
3.Uterine inertia

40. SECONDARY ARREST OF
CERVICAL DILATATION
(CERVICAL DYSTOCIA)
When the cervix failed to be dilated for 2 hrs

41. SECONDARY ARREST OF HEAD DESCENT
When the head failed to be descend for 2 hr

42. PROTRACTED SECOND STAGE
•The median duration of the 2
nd
stage of labour is 2 hrsin
primigravida , 1 hrin multigravida
•Causes
1.Rigid perineum
2.Occipitoposterior position
3.Uterine inertia
4.CPD
5.Epidural anesthesia

43. PRECIPITATE LABOUR
Activephaseofcervicaldilationhas3stages
(acceleration,maximumslope,deceleration)
Maximumslopeofdilatationof5cm/hrormore.

45. Thank you
Dr. Maraey M. Khalil, MBBCh, MSc, MD
lecturer and consultant in Obstetrics and Genecology, Aswan University, Egypt
[email protected]
https://www.linkedin.com/in/maraey-menoufy-1798b2103/
https://www.researchgate.net/profile/Maraey_Menoufy2
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