1. Partograph-
Made easy for undergraduates
Dr. Debraj Mondal
MBBS, MS, DNB, MRCOG (1)-UK

2. What is Partograph or Partogram ?
• Is a tool which graphically represents key
events during labour.
• The partograph is an inexpensive and
accessible tool that can effectively monitor
the progress of labour

3. Objectives
• to improve health care and
• To reduce maternal and fetal morbidity and
death.

4. It helps the
care provider
•to identify slow progress
in labour early,
to initiate
appropriate
interventions
•to prevent prolonged
and obstructed labour.
Why should we use a partograph ?

5. First Obstetrician to describe the progress of labour
graphically
• E.A. Friedman was the first
obstetrician to describe the
progress of labour graphically in
1954.
• He reported the change in cervical
dilatation occurring in labour.
• The progress was recorded in
centimetres of dilatation per hour.
• The resulting graph was an S-
shaped curve.

6. Types of partographs:
• Philpott and Castle developed a
partograph, a practical tool for recording
all intrapartum details, not just cervical
dilatation
• Since the 1990's, WHO
• has published three different types of the
partograph

7. A. The composite
partograph--
1994
• A latent phase
of 8 hr
• An active phase
starting at 3 cm
cervical
dilatation .

8. B. The modified WHO
partograph for use
in hospitals was
published in 2000
 No latent phase
 Active labour starts
from 4 cm

9. C. simplified partograph
by WHO
This version simplifies the partograph for
use at primary level.
Colour codes (green, yellow and red)
help the user to identify normal
labour (green) and distinguish it from
slow progress (yellow: watch out;
red: danger).

10. Why latent phase is removed
• Latent phase is most often a "retrospective diagnosis".
• Having a arbitrary time limit for latent phase of 8 h increases the
risk of incorrect diagnosis of labour and could thus increase the risk
of non-indicated interventions and morbidity.
• On the other hand, the risks of "prolonged latent phase" in the
presence of intact membranes and no other complications is almost
minimal.
• Lastly, the "transfer" from latent to active phase (broken line) by
health workers was reportedly a major source of confusion and
error in partography.

11. Observations charted on the Partograph
A) The Progress of labour
• Cervical dilatation
• Descent of fetal head
• Uterine contractions – duration,
frequency
B) Fetal condition
• Fetal heart rate
• Membranes and liquor
• Moulding of the fetal skull
C) Maternal condition
• Pulse/ BP / Temp
• Urine – volume, acetone, protein
• Drugs & IV Fluids
• Oxytocin regime

12. Starting a Partograph
A partograph should be started only when
a woman is in active phase of labour-
• Cervical dilatation must be 4 cms or more

13. Starting a Partograph
• 1st part is patient particulars.
• Name, Gravida, Para, Hosp. No.
• DOA, TOA
• Ruptured membrane, Hours

14. Cervical dilatation
• Assessed only after 4 cm dilatation.
• Plotted every 4 hr
• Marked with “X” on the cervi-graph

15. What is alert line ?
• an oblique line on the
Cervical Dilatation Area
of the partograph that
goes from 4 to 10 cm of
cervical dilatation
• Represents the rate of
cervical dilatation 1 cm
per hour. This rate is
considered to be the slowest
rate of cervical dilatation
among nulliparae in normal
labour.

16. What is action line ?
• An oblique line in the Cervical Dilatation Area of the partograph that
runs parallel and four hours to the right of the Alert Line
• If the cervical dilatation graph reaches or crosses the Action line, it
indicates dangerously slow progress of labour.
• In this case, full medical assessment must be performed and decision
must be made about the cause of the slow progress, and appropriate
action taken

17. Recommendations for taking
action

18. left of or on the alert line
• Do not augment with oxytocin or intervene unless
complications develop
• ARM may be done at any time in the active phase

19. Between Alert and Action lines
In a Health Centre:
Transfer to hospital with facilities
for Cesarean section, unless
Cervix is almost fully dilated
ARM may be performed if
membranes are still intact and
observe labour for a short
period before transfer
In Hospital:
Perform ARM if membranes are
intact and continue routine
observations

20. At or Beyond Active Phase Action Line
Full medical assessment
Consider IV infusion/bladder
catheterization/analgesia
Options:
Delivery if fetal distress or
obstructed labour
Oxytocin augmentation if no
contraindication
Supportive therapy (only if
satisfactory progress is now
established and dilatation
could be anticipated at
1cm/hr or faster)

21. Descent of fetal head
It is measured in terms of fifths above the pelvic brim
• The width of the 5 fingers is a guide to the expression in fifths
of the head above the brim. A head that is mobile above the
brim will accommodate the full width of 5 fingers
• Plotted with “0” on the lower part of cervicograph.

23. As the head descends, the portion of the head remaining above
the brim will be represented by fewer fingers

24. • It is generally accepted that the head is
engaged when the portion of the head above
the brim is represented by 2 fingers are less

25. Uterine contractions
• Calculated per 10 min.
• Weak (<20 sec) Dots.
• Moderate (20 – 40 sec) Crosshatchs.
• Strong (>40 sec) Darkened.
Weak
Moderate
Strong

26. Fetal condition
1. Fetal Heart rate
2. Status of the membranes
3. Moulding

27. Fetal Heart Rate
Listen
• Patient in left lateral position
• Just after the contraction has
passed its strongest phase
• For 1 full minute,
• every 30 min
• if abnormal every 15mins
• If abnormal over 3
observations, take action
Record
• At the top of the Partograph
• Every half hour

28. Fetal Heart Rate
FHR Interpretation
110-160 NORMAL
100-109
Or 161-180
Borderline- Be alert
>180 Fetal Tachycardia
<100 Fetal Bradycardia
& Fetal distress
Fetal Tachycardia is the initial sign of fetal distess

29. Membranes & Liquor
State of Liquor Record
• Membranes intact I
• Clear C
• Meconium M
• Absent A
• Blood Stained B

30. Fetal condition- Moulding
Sagittal suture
Metopic suture
Coronal suture

31. Fetal condition- Moulding
State of Moulding Record
• Bones are separated &
sutures felt O
• Bones are just touching
each other 1+
• Bones are overlapping 2+
• Bones are severely
overlapping and not
separable 3+

32. Lower part of Parograph
1. Drugs
2. Vitals

33. Drugs
Recorded at the foot of
the Partograph
• Oxytocin:
• IV Fluids
• Other Drugs: Drotin,
Epidosin, Tramadol,
Pethidine,
• Epidural

34. Oxytocin dose calculation
• One ampoule of oxytocin contains 5 Units of
drug.
• Dissolve in 500 ml NS.
• Conc. is 10 Unit per Litre (10 U/L).
• Half ampoule is dissolved in 500 ml NS
• Conc. Is 5 Unit per Litre (5 U/L)

35. Oxytocin dose calculation
• 15 drops is equivalent to 1ml of fluid.
• Suppose we have taken oxytocin@5 U/L
• Each Litre of fluid contains 5 unit drug
• Each Litre of fluid contains 5000 mili-unit (mU)
• Each ml of fluid contains 5 mili-unit (mU)
• Each 15 drops of fluid contains 5mU
• The rate is 15 drops per min to start with.

36. Maternal Condition
Recorded at the foot of the
Partograph
• Pulse: every half hour
• BP: every 4 hrs or more
frequently
• Temp: every 4 hrs or
more frequently
• Urine: Protein
,Acetone,Volume

37. Can the partograph be used only for normal ( vertex)
presentation ?
• Use of the partograph is not restricted to vertex
presentations.
• It can be used in all situations where vaginal birth can be
expected. For example, it can be used in monitoring progress of labour
in breech presentation. However in this situation, descent of the fetal
head and moulding are not assessed and recorded on the partograph.
• The partograph can also be used in face presentation.
• Vaginal birth is not anticipated with transverse lie and brow
presentation and hence the partograph is not used.

38. How should the labour progress be monitored in
second stage of labour ?
• The condition of mother and the fetus should be monitored
more frequently in the second stage of labour.
• The cervix is fully dilated and while no further recordings of
cervical dilatation are required,
• it is important to monitor other information e.g. frequency
and strength of uterine contractions, descent of the fetal
head, fetal heart rate, colour of amniotic fluid, medications
administered, etc.

39. Inadequate uterine contractions corrected with
oxytocin
Q.1

40. Q.2

41. Q.2

42. Q.3

43. Q.3

44. Q.4

45. Q.4

46. Q.5

47. Q.5