Use of the Partograph

Module 6
Use of the Partograph
Session Objectives:
By the end of the session, the participants will be able to:
 Define the partograph
 Know the evidence that supports the advantages of using the
partograph
 Describe the partograph and its components in detail
 Correctly fill in and analyze a partograph
Major Killers of Mothers and Newborns
Major Causes of Maternal
Deaths Major Causes of Newborn Deaths
 Hemorrhage  Sepsis
 Sepsis  Asphyxia
 Pre-eclampsia/eclampsia  Prematurity
 Unsafe abortions
 Obstructed labor
 Evidence-Based Interventions to Reduce
Maternal Deaths
Source: World Health
Magnesium
Organization, 1997 sulfate

Active management of
Family planning and Eclampsia
the third stage of labor
12%
postabortion care Severe bleeding
24%
Unsafe
abortion
13%

Antibiotics
Infection Indirect causes
15% 20%*
Tetanus toxoid
immunization Obstructed Other Iron supplements,
& clean delivery labor direct
Intermittent preventive
8% causes
Partograph 8%* treatment of malaria , and
Cesarean section antiretrovirals for HIV
 Evidence-Based Interventions to Reduce
Newborn Deaths
• Syphilis control • Tetanus toxoid
• Folate supplementation immunization of
Congenital
• Malaria control anomaly mother
• Antenatal corticosteriod 7% Infection • Clean delivery
• Treatment of bacteriuria 36% • Cord care
• Early and exclusive
Complications of • Sepsis/
breastfeeding
prematurity pneumonia
27% • Tetanus • Antibiotics for mother
• Diarrhea and baby

• Kangaroo mother Other

care Asphyxia • Warming
7%
• Birth spacing 23% • Resuscitation
• Maternal nutrition • Skilled birth attendants

Adapted from Lancet 2005

Low birth weight is a significant
contributor to 40–70% of neonatal deaths.
 A Skilled Attendant at Every Birth
 Every year, more than 500,000
women die from causes related
to pregnancy and childbirth.
 An additional 300 million
women suffer from short- or
long-term illnesses related to
childbearing.
 Most maternal deaths and
morbidities occur in developing
countries, where skilled
attendance is often scarce.
Source : AbouZahr C and Wardlaw T. Maternal mortality at the end of a decade: Signs of progress? Bull World
Health Organ 2001; 79(12): 1177; Interagency Group on Safe Motherhood 2000.
A Skilled Attendant at Every Birth (cont’d)
A skilled attendant has the knowledge and skills to:
 Use best practices to facilitate normal labor, childbirth, and the
immediate newborn/postpartum period
 Recognize the onset of complications and stabilize the woman or
newborn if necessary
 Manage complications and/or timely refer the woman or newborn
to a higher level of care if necessary.
Definition of a Partograph
A partograph:
 Is a graphic representation of the progression of labor and the
condition of the mother and fetus.
A partograph is a tool, not an end in itself. It is used to:
 Guide early detection of prolonged or obstructed labor, and
 Inform decision-making in the management of labor.
WHO recommends using the partograph to monitor all
women during labor.
Who Can Use a Partograph?
Skilled birth attendants (doctor, nurses, lady health visitors,
and midwives) can use a partograph to:
 Observe, conduct, and record normal vaginal delivery
 Perform vaginal examination and accurately assess the
degree of cervical dilatation
 Accurately plot cervical dilatation.
 Analyze findings on partograph and take immediate action
Why Use a Partograph?
Use of a partograph:
 Encourages increased vigilance and alerts the provider to signs of
fetal or maternal distress at an early stage, when it may be necessary
to take action;
 Allows providers to know when it might be necessary to augment
labor to increase the rate of dilatation, but also reduces the
unnecessary use of oxytocin that can result in hyper stimulation and
fetal hypoxia; and
 Helps to ensure timely cesarean section, which is sometimes
necessary for safe delivery of a hypoxic fetus.
Objectives of Care during Labor and
Childbirth
 Protect the lives of women
and newborns
 Facilitate normal labor and
childbirth
 Detect and manage
complications in a skilled and
timely manner
The Three Stages of Labor
 First stage: Lasts from initial dilatation of the cervix to full
dilatation
 Second stage: Begins at full dilatation of the cervix and ends when
the baby is born
 Third stage: Lasts from the birth of the baby until the placenta is
expelled
Monitoring during Labor
During labor, the skilled birth attendant monitors:
 Progress of labor
 Cervical dilatation
 Contraction pattern
 Maternal well-being
 Pulse, temperature, blood pressure
 Urine voided
 Fetal well-being
 Fetal heart rate and pattern
 Color of amniotic fluid
The Parts of the Partograph

Progress of labor

Maternal and fetal well-being

 Alert line
D
I
Action
L line Parallel
and 4
A hours to
T the right of
I alert line
O
N
Recording Findings on the Partograph
Start by labeling the record with pertinent patient identifying
information:

Name :

Para : Gravida : Hospital No:

Date of admission : Time of admission :

Ruptured Membranes : Hrs:

Recording Findings on the Partograph
(cont’d)
Plot the progress of labor:
 Plot the cervical dilation using an X.
 Start when woman is in active labor (4 cm or more) and is
contracting adequately (3–4 contractions in 10 minutes).
 X

Start plotting on alert line at the

intersection corresponding to the
cervical dilation finding.
 X

X
4:00 p.m. 8:00 p.m.

Perform an internal examination every four

hours. Avoid unnecessary, frequent vaginal
exams.
▪ Remember to write the time that each
observation was made.
 X

X
4:00 p.m. 8:00 p.m.

Connect the Xs to demonstrate the

pattern of labor.
Example

x
1:00 a.m.

A woman (gravida1, para 0) is being monitored by a

midwife at home. Her initial exam at 1:00 a.m.
showed a 4 cm dilated cervix.
Example

x
1:00 a.m. 5:00 a.m.

At 5:00 a.m., another exam showed an 8 cm

dilated cervix.
Example

x
x

x
1:00 a.m. 5:00 7:00 a.m.
a.m.

At 7:00 a.m., the patient is 9 cm dilated, intact

membranes. Crossed alert line, moving toward
action line.
Other Findings to Note (and Record) during Exam

Status of membranes
 If intact, write I.
 If ruptured, note color of amniotic fluid, and write:
 C, if clear,
 M, if meconium stained,
 A, if absent, and
 B, if bloody.
Monitor and Record the Findings: Active
Phase of Labor
 Oxytocin: Record the amount of oxytocin per volume IV fluids in
drops per minute every 30 minutes when used.
 Drugs given: Record any additional drugs given.
 Pulse: Record pulse every hour.
 Blood pressure: Record blood pressure every hour.
 Temperature: Record temperature every hour.
 Protein, acetone, and volume: Record when urine is passed.
Record Newborn’s Findings
Record newborn’s findings on the partograph:
 Date and time of birth
 Single/ Twin/Multiple
 Condition: Alive/Dead
 Mode of delivery (NVD /LSCS)
 Weight of the baby
 Sex of the baby
Distinguishing a Normal Labor Pattern
from an Abnormal Labor Pattern
X

4:0
X 6:00 8:00 10:00
p.m p.m. p.m. p.m.
.

Note that, based on the structure of the

partograph, as soon as 4 cm is reached,
the cervix should dilate normally at a rate
of approximately ≥ 1 cm/hour.
 X
X

X
4pm
8pm 10pm

Perform internal examination every four hours, or

more often if necessary, and plot findings each
time
▪ Also, do not forget to write the time for each
observation made.
 X X

X X
Normal Labor

X
4:00 6:00 8:00 10:00
p.m. p.m. p.m. p.m.

Progress of labor is normal if plotting

stays on or to the left of the alert line.
 Abnormal Labor
X

X
4:00 6:00 8:00 10:00 12:00 2:00
p.m. p.m. p.m. p.m. a.m. a.m.

Plotting that passes the alert line—especially if

it reaches or passes the action line—indicates
abnormal progress of labor.
Plotting that Passes the Alert Line

If plotting passes the alert line:

 Reassess woman and consider referral if facilities not available to deal
with obstetric emergencies (unless delivery is imminent)
 Alert transport services
 Monitor woman intensively
Plotting that Passes the Alert Line
(cont’d)
 Empty bladder
 Ensure adequate hydration but omit solid foods
 Encourage upright position and walking if woman wishes
 Monitor intensively (if referral long, reassess in two hours and
refer if no progress)
If the partograph passes the action line, refer urgently to a
comprehensive emergency obstetric care facility, unless imminent
delivery.
Plotting that Reaches the Action Line
 If plotting reaches the action
line:
 The patient must already be in
a comprehensive emergency
obstetric care facility, a
decision made about the cause
of slow progress, and
appropriate action taken.
of a Partograph but Do Need Urgent
Referral
 Antepartum hemorrhage
 Severe pre-eclampsia and  Multiple pregnancies
eclampsia  Malpresentation
 Fetal distress  Very premature baby
 Previous cesarean section  Obvious obstructed labor
Summary
WHO recommends using the partograph to monitor all
women during labor.
 A partograph is a decision-making tool to be filled out during
labor.
 Timely decisions and actions can prevent many maternal and
neonatal mortalities and morbidities.
Thanks!