Partograph It is a visual/graphical representation of related values or events over the course of labor. Relevant measurements might include statistics such as cervical dilation, fetal heart rate, duration of labour and vital signs. A concept of recording the progress of labour on a chart was started first by Freidman in 1954 who used graphic records of cervical dilatation in labour. This was further developed and extended by philpot in1972.The WHO partograph has been modified to make it simpler and easier to use. The latent phase has been removed and plotting on the partograph begins in the active phase when the cervix is 4 cm dilated.

PURPOSE To provide an accurate record of the progress in labour, so that any delay or deviation from normal may be detected quickly and treated accordinglyA decision-making tool rather than only a record. Start when dilation reaches 4 centimeters. Use through out labor to help: Evaluate fetal and maternal well-being Assess progress of labor Identify problems Guide decision-making for care Provide a record of findings

Advantages A single sheet of paper represents a dynamic documentation of the events in labour as they unfold in time. It provides a record of parameters denoting maternal and fetal well being. It can predict deviation from duration of labour so appropriate steps could be taken in times. Saves working time of staff against writing labours notes in long hand. It facilitates handover procedure of staffs. Improves perinatal outcome Avoindance of difficult obstetric interventions. No need to record labour events repeatedly. Gives clear picture of normality and abnormality in labour. Educational value for all staff.Indication of using partograph: Partograph must be used when labour is expected to be normal. Before using partograph check for any complication of pregnancy which required immediate action.Contraindication for using partograph: Antepartum haemorrhage Diagnosed CPD Severe pre-eclampsia and eclampsia Fetal distress Severe anemia Multiple pregnancy Mal presentation Premature labour Obstructed labour

Principles of plotting partograph Active phase of labour commence at 4 cm cervical dilation. The latent phase of labour should last not longer than 8 hours. During active labour, the rate of cervical dilatation should not be slower than 1cms/hours. A lag time at 4 hours between a slowing of labour and the need for intervention is unlikely to compromises the fetus or the mother and avoid unnecessary intervention. PV examination should be performed as infrequently as it is compatible with safe practice. It is better to use a partograph with pretest line, although too many lines may added further confusion.

Components of PartographA- Basic information (Patients identification)B- Fetal heart rateC- Amniotic membrane and mouldingD- Descent of fetal head E- Cervical dilatationF- Uterine contractionG- Oxytocin dripH- Drug and other intravenous fluidI- Not usedJ- Maternal condition(vitals sign)K- Urine analysis

Patient basic information: Fill out name, gravida, para, hospital number, date and time of admission and time of ruptured membranes and time of onset of true labour pain. Fetal heart rate: The rate of the fetal heart indicates the state of fetus inside the uterus. Record every half hour. Plot one dot (.) in the line at the level of the heart rate indicated in figure on left hand. Each squire in the graph indicates half hour as fetal heart is recorded every half hour. The recording is more frequent as the labour progresses. The FHR recording is done just after uterine contraction is over. The average baseline FHR should be between 100-180 beats per minute. If there are fetal heart rate abnormalities (180 beats per minute) suspect fetal distress.Amniotic fluid: State the state of membranes whether it is (+) or (-) and if it is ruptured record the colour of amniotic fluid at every vaginal examination and time of rupture. The state of liquor can assist in assessing fetal condition after the rupture of membranes. Normally the amniotic sac contains whitish watery fluid, occasionally with flakes of vernix caseosa. It may be green, Yelloish green in colour when stained with meconium.Recording is done as: I: membranes intact; C: membranes ruptured, clear fluid; M: meconium-stained fluid; B: blood-stained fluid. A: Liquor not seen or abscent.Moulding: Moulding is an important finding as to know how well the pelvis will accommodate the fetal head. It is the alteration of the shape of the forecoming head that takes place during its passage through the birth canal or It is a state of reduction or loss of space between skull bones. Presence of increased moulding of the head in the pelvis indicates CPD. Presence of caput makes it difficult to assess moulding but that is itself is sign of CPD. Recording of degree of moulding 0: Bones are separated 1: sutures apposed ;(+) 2: sutures overlapped but reducible ;(++) 3: sutures overlapped and not reducible. (+++) Cervical dilatation: Assessed at every vaginal examination and marked with a cross (X). Begin plotting on the partograph at 4 cm.The graph consists of homogenous squires, ten square vertically, each squire indicate one centimeter of cervical dilatation. There are 24 squares spread horizontally, each square indicating one hour each. The crosses in the graph are joined by a continuous line. The climbing tendency of this line normally lies on the middle of the graph. When this line crosses the midline take this as warning to be caution or alert. Alert line: A line starts at 4 cm of cervical dilatation to the point of expected full dilatation at the rate of 1 cm per hour. Action line: Parallel and 4 hours to the right of the alert line. Necessary action should be taken if it crosses the action line.Note: Remember, first cervical dilatation should be plotted on alert line. Subsequent cervical dilatation is plotted on the basis of the time of first cervical dilatation. Descent assessed by abdominal palpation: Refers to the part of the head (divided into 5 parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis. At 5/5, the 5 parts of the head is palpable above the symphasis pubis or brim in which the both sinciput and occiput is palpable at same level if the head is deflexed and sinciput is higher than occiput in well flexed head. At 4/5, sinciput high and occiput easily felt just above the pelvic brim. At 3/5 sinciput easily felt and occiput felt at pelvic brim. At 2/5, sinciput felt and occiput just felt. At 1/5 sinciput felt, occiput not felt. At 0/5 no of the head is palpableHours: Refers to the time elapsed since onset of active phase of labour (observed or extrapolated). Time: Record actual time according to the hours of active phase of labour started.Uterine Contractions: Chart every half hour; palpate the number of contractions in 10 minutes and their duration in seconds. The squires in the vertical columns are shaded according to the duration and intensity. The graph has five squires vertically and 48 squires horizontally.Each squire represents one contraction lasting 10 seconds. In normal labour, contractions usually become more frequent and last longer as labour progresses. Shade the square according to duration of contractions as follows: Less than 20 seconds: Between 20 and 40 seconds: More than 40 seconds: Oxytocin: Record the amount of oxytocin per volume IV fluids in drops per minute every 30 minutes when used. This consists of two lines; one for the record of oxytocin per liter of intravenous fluid and other one is for drop of fluid per minute. The recording can be made at the interval of 30 minutes as the uterine contraction.Drugs given: Record any additional drugs given. There are 24 columns where the drugs given are recorded at the particular point of time. This includes sedatives, antibiotics, IV fluids etc.Pulse: Record every 30 minutes and mark with a dot (). Blood pressure: Record every 4 hours and mark with arrows. Temperature: Record every 2 hours. Urine analysis (Protein, acetone and volume): Record every time urine is passed. Record volume of urine output. Record the delivery details to the right of action line. Type of delivery. Date and time of delivery Birth weight sex of the baby.

The modified WHO PartographSample partograph for normal labour A primigravida was admitted in the latent phase of labour at 5 AM: - fetal head 4/5 palpable; - cervix dilated 2 cm; - 3 contractions in 10 minutes, each lasting 20 seconds; - normal maternal and fetal condition. Note: This information is not plotted on the partograph. At 9 AM: - fetal head is 3/5 palpable; - cervix dilated 5 cm; Note: The woman was in the active phase of labour and this information is plotted on the partograph. Cervical dilatation is plotted on the alert line. - 4 contractions in 10 minutes, each lasting 40 seconds; - Cervical dilatation progressed at the rate of 1 cm per hour. At 2 PM: - fetal head is 0/5 palpable; - cervix is fully dilated; - 5 contractions in 10 minutes each lasting 40 seconds; - Spontaneous vaginal delivery occurred at 2:20 PM.

Partograph showing prolonged active phase of labour Partograph showing prolonged active phase of labour The woman was admitted in active labour at 10 AM: - fetal head 5/5 palpable; - cervix dilated 4 cm; - inadequate contractions (two in 10 minutes, each lasting less than 20 seconds). At 2 PM: - fetal head still 5/5 palpable; - cervix dilated 4 cm and to the right of the alert line; - membranes ruptured spontaneously and amniotic fluid is clear; - inadequate uterine contractions (one in 10 minutes, lasting less than 20 seconds). At 6 PM: - fetal head still 5/5 palpable; - Cervix dilated 6 cm; - Contractions still inadequate (two in 10 minutes, each lasting less than 20 seconds). At 9 PM: - Fetal heart rate 80 per minute; - Amniotic fluid stained with meconium; - No further progress in labour. Caesarean section was performed at 9:20 PM due to fetal distress. Note that the partograph was not adequately filled out. The diagnosis of prolonged labour was evident at 2 PM and labour should have been augmented with oxytocin at that time Partograph showing obstructed labourIt is a sample partograph showing arrest of dilatation and descent in the active phase of labour. Fetal distress and third degree moulding together with arrest of dilatation and descent in the active phase of labour in the presence of adequate uterine contractions indicates obstructed labour. The woman was admitted in active labour at 10 AM: - fetal head 3/5 palpable; - cervix dilated 4 cm; - three contractions in 10 minutes, each lasting 2040 seconds; - clear amniotic fluid draining; - first degree moulding. At 2 PM: - fetal head still 3/5 palpable; - cervix dilated 6 cm and to the right of the alert line; ght improvement in contractions (three in 10 minutes, each lasting 40 seconds); - second degree moulding. At 5 PM: - fetal head still 3/5 palpable; - cervix still dilated 6 cm; - third degree moulding; - fetal heart rate 92 per minute. Caesarean section was performed at 5:30 PM.