The Partograph 1

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 action The 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.

This is the SIMPLIFIED WHO partograph and the one that we will be using during this training.

OBJECTIVES To understand the concept of the WHO partograph To explain to mothers the significance of the graph To record the observations accurately on the graph To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral

Monitor during labor… Progress of labor Maternal well being 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 6

The parts of the partograph Progress of labor The 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-being 7

DILATATION Alert line Let 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.

Parallel and 4 hours to the right of alert line DILATATION Alert line Action line Parallel and 4 hours to the right of alert line Parallel 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.

Conditions that do not need the use of partograph Antepartum hemorrhage Severe pre-eclampsia and eclampsia Fetal distress Previous cesarean section Multiple pregnancy Malpresentation Very premature baby Obvious obstructed labor The 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.

II. Recording the findings in the partograph Start by labeling the record with pertinent patient identifying information.

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)

Start plotting on alert line in the intersection corresponding cervical dilatation finding 13

X You 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

X If she is first seen at 8 cm, then start at the 8 cm line but still on the alert line. 15

X 4pm Indicate 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

X X X 4pm 8pm 10pm Perform internal examination every 4 hours, or more often if necessary, and plot findings each time Also, do not forget to write the time each observation was made 17

Connect the “X”s to demonstrate the pattern of labor 4pm 8pm 10pm Connect the “X”s to demonstrate the pattern of labor

EXAMPLE x 1am A G1P0 is being monitored by a midwife. Her initial IE at 1 am showed 5 cm dilated cervix. Encourage audience participation. 19

EXAMPLE x x 1am 5am At 5 am, another IE showed 9 cm dilated cervix. 20

EXAMPLE At 7 am, the patient is 10 cm dilated, intact BOW. x x x 1am 21

III. Distinguishing normal from abnormal labor pattern

X X X X X 4pm 6pm 8pm 10pm Progress of labor is normal if plotting stays on or to the left of the alert line (green part)

X X 4cm = active labor X 4pm 6pm 8pm 10pm 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 ≥ 1 cm/hour. 24

X X X 4pm 6pm 8pm 10pm 12am 2am Plotting that passes the alert line (yellow part) more so if it reaches or passes the action line (red part) indicates abnormal progress of labor

If plotting passes alert line … Reassess woman and consider referral if facilities are not available to deal with obstetric emergencies, unless delivery is imminent Alert transport services Monitor intensively 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 taken EmOC facility is a hospital with capability for Emergency Obstetric Care.

Maternal and fetal well-being Progress of labor The 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-being 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

IV. Other findings to note (and record) during IE Status of membranes, write “ I ” if intact If ruptured, note color of amniotic fluid, write “ C ” if clear “ M ” if meconium stained “ A ” if absent “ B ” if bloody

Monitor every 4 hours* and record the findings Blood Pressure Pulse rate Temperature Urine voided (yes or no) * More frequently, if indicated

Monitor more frequently and record the findings Number of contractions in 10 minute period Fetal heart rate in 1 full minute The findings for these should be recorded every hour.

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

EXERCISES Indicate whether the progress of labor in the following partographs are normal or abnormal.

x Case 1 x 10pm 2am Normal

Case 2 X X X X 8pm 12mn 2am 4am Abnormal

X Case 3 X x 9pm 1am 3am Normal

EXERCISES Plot the observations in the following cases.

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.

Maria, G1P0 Date Today X X X X 2am 6am 8am I 3 140 140 88 88 8:30 C I Check the answers individually. C 3 140 140 88 88 110/70 110/70 8:35 8:30

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/min Give the participants 3-5 minutes to answer this exercise.

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. M 3 3 36.5 36.5 37.5 80 80 92 120/80 120/80 110/70

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 same Give the participants 3-5 minutes to answer this exercise. 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. I I C C 2-3 3 140 140 140 144 36.5 36.5 36.5 84 84 120/80 120/80 120/80 5 7 8 44

RECAP Significance and use of the partograph Parts of the partograph and information contained in it Recording or plotting of clinical observations Interpretation of the recorded findings and decision on referral

Good day! 46