2 I. The Partograph A tool to help in management of labor Guides birth attendant to identify women whose labor is delayed and therefore decide appropriate actionThe partograph is a useful tool for monitoring the progress of labor. Use it to avoid unnecessary interventions so maternal and neonatal morbidity are not needlessly increased, to intervene in a timely manner to avoid maternal and neonatal morbidity or mortality and to ensure close monitoring of the woman in labor.
3 This is the SIMPLIFIED WHO partograph and the one that we will be using during this training.
4 OBJECTIVES To understand the concept of the WHO partograph To explain to mothers the significance of the graphTo record the observations accurately on the graphTo interpret the recorded findings, recognize deviation from the norm, and decide on timely referral
5 Monitor during labor… Progress of labor Maternal well being Cervical dilatationContraction patternMaternal well beingPulse, temperature, blood pressureUrine voidedFetal well beingFetal heart rate and patternColor of amniotic fluid6
6 The parts of the partograph Progress of laborThe upper colored portion is where you plot the progress of labor.The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.Maternal and fetal well-being7
7 DILATATIONAlert lineLet us enlarge the upper portion of the partograph. As you can see it is divided evenly into small boxes by gridlines vertically and horizontally.Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to 10.While the vertical gridlines indicate the time, in hours, the patient is in active labor.The upper portion is also divided into 3 colors – green, yellow, and red.The boundary between the green and yellow parts forms a diagonal line which is highlighted here. This is designated as the alert line which starts at 4 cm. up to 10 cm.
8 Parallel and 4 hours to the right of alert line DILATATIONAlert lineAction lineParallel and 4 hours to the right of alert lineParallel and 4 hours to the right of the alert line is another line formed by the boundary between the yellow and red part which is again highlighted here. This is the action line. Note that it too starts at 4 cm and ends in 10 cm.
9 Conditions that do not need the use of partograph Antepartum hemorrhageSevere pre-eclampsia and eclampsiaFetal distressPrevious cesarean sectionMultiple pregnancyMalpresentationVery premature babyObvious obstructed laborThe partograph need not be used in all pregnant or laboring patients especially those who are for cesarean delivery like those with malpresenting babies (breech or transverse lie), those with scarred uteri, those with antepartum hemorrhage (like placenta previa). It is also not needed in those who have to be delivered immediately because of fetal distress or those with severe uncontrolled pre-eclampsia and eclampsia. Likewise it may not be appropriate for those with twins or very premature baby.
10 II. Recording the findings in the partograph Start by labeling the record with pertinent patient identifying information.
11 Plotting the progress of labor Plot only the CERVICAL DILATATION using the symbol “X”Start when woman is in ACTIVE LABOR (4 cm or more) and is contracting adequately (3-4 contractions in 10 minutes)
12 Start plotting on alert line in the intersection corresponding cervical dilatation finding 13
13 XYou do not always have to start the plotting in the 4 cm line since not all patients are first seen at this cervical dilatation. If the patient arrives at 6 cm cervical dilatation start plotting in the 6 cm line but still in the alert line.14
14 XIf she is first seen at 8 cm, then start at the 8 cm line but still on the alert line.15
15 X4pmIndicate the time the IE was made (and therefore, the observation was plotted)Write this in the vertical line itself where you plot the “X”, NOT the space after it
16 XXX4pm8pm10pmPerform internal examination every 4 hours, or more often if necessary, and plot findings each timeAlso, do not forget to write the time each observation was made17
17 Connect the “X”s to demonstrate the pattern of labor 4pm8pm10pmConnect the “X”s to demonstrate the pattern of labor
18 EXAMPLEx1amA G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix.Encourage audience participation.19
19 EXAMPLExx1am5amAt 5 am, another IE showed 9 cm dilated cervix.20
20 EXAMPLE At 7 am, the patient is 10 cm dilated, intact BOW. x x x 1am 21
21 III. Distinguishing normal from abnormal labor pattern
22 XXXXX4pm6pm8pm10pmProgress of labor is normal if plotting stays on or to the left of the alert line (green part)
23 XX4cm = active laborX4pm6pm8pm10pmNote that based on the structure of the partograph as soon as 4 cm is reached the cervix should dilate normally at a rate of ≥ 1 cm/hour.24
24 XXX4pm6pm8pm10pm12am2amPlotting that passes the alert line (yellow part) more so if it reaches or passes the action line (red part) indicates abnormal progress of labor
25 If plotting passes alert line … Reassess woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminentAlert transport servicesMonitor intensively26
26 If plotting reaches the action line… the patient must be already in an EmOC facility, a decision made about the cause of slow progress, and appropriate action takenEmOC facility is a hospital with capability for Emergency Obstetric Care.
27 Maternal and fetal well-being Progress of laborThe upper colored portion is where you plot the progress of labor.The lower portion is where you are supposed to write your other observations particularly the findings of your monitoring of the maternal and fetal well-being.Maternal and fetal well-being28
28 As I have said below the colored part is where you are supposed to write your other observations such as the character of the amniotic fluid, the number of contractions in 10 minute period, the FHR per minute, whether the mother voided or not, her axillary temperature in centigrade, her pulse rate per minute, her BP, whether the patient is on oxytocin or not, and the patient’s other problems if any.29
29 IV. Other findings to note (and record) during IE Status of membranes, write“ I ” if intactIf ruptured, note color of amniotic fluid, write“ C ” if clear“ M ” if meconium stained“ A ” if absent“ B ” if bloody
30 Monitor every 4 hours* and record the findings Blood PressurePulse rateTemperatureUrine voided (yes or no)* More frequently, if indicated
31 Monitor more frequently and record the findings Number of contractions in 10 minute periodFetal heart rate in 1 full minuteThe findings for these should be recorded every hour.
32 If woman is admitted in LATENT PHASE of labor (less than 4 cm dilated) – record only other findings (BP, FHT etc).If she remains in latent phase for next 8 hours (labor is prolonged), transfer her to hospital.33
33 EXERCISESIndicate whether the progress of labor in the following partographs are normal or abnormal.
37 EXERCISESPlot the observations in the following cases.
38 Case 4:Maria, G2P1 was admitted today at 2 am, IE showed a 5cm dilated cervix, cephalic, intact BOW. BP=110/70, PR=88/min, afebrile. FHT=140/min.She had moderate contractions (3 in 10 min). At 6 am, the BOW ruptured with clear amniotic fluid. IE showed 8 cm dilated cervix. Vital signs were the same.At 8 am, cervix was 9 cm. She delivered spontaneously at 8:30 am. 10 u oxytocin was given IM. Placenta was delivered complete at 8:35 am.Give the participants 3-5 minutes to answer this exercise.
39 Maria, G1P0 Date Today X X X X 2am 6am 8am I 3 140 140 88 88 8:30 C ICheck the answers individually.C31401408888110/70110/708:358:30
40 Case 5:Lourdes, G4P2 was admitted at 1 pm today due to watery vaginal discharge. The cervix was 3 cm, cephalic, intact BOW. BP=120/80, PR=80/min, T-36.5.At 5pm, contractions were moderate, 3 in 10 min. IE showed cervix 4 cm dilated. Vital signs remained the same.At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, meconium stained fluid. BP-110/70, PR-92/min, T-37.5, FHT-140/minGive the participants 3-5 minutes to answer this exercise.
41 Lourdes, G4P2 Date Today X X X 5pm 9pm 1am M 3 3 36.5 36.5 37.5 120/80 Check the answers individually.M3336.536.537.5808092120/80120/80110/70
42 Case 6:Marites, G1P0 was admitted at 6 pm. BP=120/80, PR-84/min, T=36.5. FHT=150/min, cervix 5 cm dilated, (+) BOW. She had 2-3 uterine contractions in 10 min.After 4 hours, IE showed 7 cm dilated cervix. Vital signs and FHT were the same.At 12 am, another IE done showed 8 cm dilated cervix, negative BOW, clear AF. FHT= 140/min.Another IE after 2 hours was the same. FHT=144/min, Vital signs sameGive the participants 3-5 minutes to answer this exercise.43
43 Marites, G1P0 Date Today X X X X 6pm 10pm 12am 2am 2 I I C C 2-3 3 140 Check the answers individually.IICC2-3314014014014436.536.536.58484120/80120/80120/8057844
44 RECAP Significance and use of the partograph Parts of the partograph and information contained in itRecording or plotting of clinical observationsInterpretation of the recorded findings and decision on referral