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WHO Partograph

For Beginner

Dr Muhammad El Hennawy

Ob/gyn specialist Rass el barr central hospital and

dumyat specialised hospital

Dumyatt E!"P#

www$mmhennawy$%&$com


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Partograph

A partograph is a graphical

record of the observations made

of a women in labour

For progress of labour and salient

conditions of the mother andfetus

It was developed and extensively

tested by the world health

organization WH


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History f PartogramFriedman'spartogram devised in !"#$ was based

on observations of cervical dilatation and foetalstation against time elapsed in hours from onset of

labour% &he time onset of labour was based on the

patient's sub(ective perception of her contractility%

Plotting cervical dilatation against time yielded the

typical sigmoid or ')' shaped curve and station

against time gave rise to the hyperbolic curve%

*imits of normal were defined


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Philpott and (astle

in )*+, introduced the concept o- .0ER#. and .(#1O2.

lines$ #he aim o- this study was to -ul-ill the needs o- paramedicalpersonnel practising obstetrics in Rhodesian -ricanprimigra3idae$ #he alert line represented the mean rate o-progress o- the slowest )45 o- patients in the -rican populationwhom they ser3ed$ lert line was drawn at a slope o- )

centimetre/hr -or nulliparous women starting at 6ero time i$e$time o- admission $ ction line drawn -our hours to the right o-the alert line showing that i- the patient has crossed the alert lineacti3e management should be instituted within 7 hours8 enablingthe trans-er o- the patient to a specialised tertiary care centre$

#he action line was subse9uently drawn two hours to the right o-the alert line


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:tudd's labour stencils It were introduced in !"+,% &hese stencils

predicted the expected pattern ofprogression of labour based on the extent ofdilataton achieved by the time the patient isadmitted -zero time.% /urves showing theaverage course of cervical dilatation wereconstructed for various dilatation on

admission% Five separate patternsrepresenting normal labour progressionwere constructed% &he curves weretranscribed onto acrylic stencils nadmission in labour0 the cervical dilatationwas assessed and a stencil was used to draw

the relevant pencil line of expected progresson the patient's cervicograph which wasthen completed% &hose crossing thenomogram line were found to have a threefold increase in instrumental delivery%


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WH partograph


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verview

&he partograph can be used by health wor1ers with ade2uate training

in midwifery who are able to 3

4 observe and conduct normal labour and delivery%

4 Perform vaginal examination in labour and assess cervical diltation

accurately

4 plot cervical diltation accurately on a graph against time

&here is no place for partograph in deliveries at home conducted by

attendants other than those trained in midwifery

Whether used in health centers or in hospitals 0 the partograph must beaccompanied by a program of training in its use and by appropriate

supervision and follow up


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b(ectives early detection of abnormal progress of a labour

prevention of prolonged labour

recognize cephalopelvic disproportion long before obstructed labour

assist in early decision on transfer 0 augmentation 0 or termin(ation of

labour

increase the 2uality and regularity of all observations of mother and

fetus

early recognition of maternal or fetal problems

the partograph can be highly effective in reducing complications fromprolonged labor for the mother -postpartum hemorrhage0 sepsis0

uterine rupture and its se2uelae. and for the newborn -death0 anoxia0

infections0 etc%.%


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Partograph function &he partograph is designed for use in all maternity settings 0 but has a

different level of function at different levels of health care in health center0 the partograph0s critical function is

to give early warning if labour is li1ely to be prolonged and to indicatethat the woman should be transferred to hospital -A*56& *I75F87/&I7 .

in hospital settings0 moving to the right of alert line serves as awarning for extra vigilance 0 but the action line is the critical point atwhich specific management decisions must be made

other observations on the progress of labour are also recorded on thepartograph and are essential features in management of labour


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/omponents of the partograph

Part ! 3 fetal condition- at top .

P2rt !! 3 progress of labour

- at middle .

Part !!! 3 maternal condition

- at bottom .

utcome 3 999999


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Part ! 3 Fetal condition this part of the graph is used to monitor and assess fetal condition

! 4 Fetal heart rate

, 4 membranes and li2uor

: 4 moulding the fetal s1ull bones

/aput


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Fetal heart rateBasal fetal heart rate?

; !mi ?tachycardia

@ !,= beats>min ? bradycardia

@!== beats>min ? severe bradycardia

Decelerations? yes/no

Relation to contractions?

Early Variable Late -----Auscultation - return to baseline

> 30 sec contraction

----- Electronic monitorin!ea" an# trouh $na#ir%

> 30 sec


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membranes and li2uor

intact membranes 999999999999999%I ruptured membranes clear li2uor 99999999%/

ruptured membranes meconium4 stained li2uor 99%%B

ruptured membranes blood C stained li2uor 9999D ruptured membranes absent li2uor9999999%%%%A


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moulding the fetal s1ull bones

Bolding is an important indication of how ade2uately the

pelvis can accommodate the fetal head

increasing molding with the head high in the pelvis is an

ominous sign of cephalopelvic disproportion

separated bones % sutures felt easily 999999%9% bones (ust touching each other 999999999%%

overlapping bones - reducible = 99999999%%%

severely overlapping bones - non C reducible . 99%%


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part!! C progress of labour

&/ervical diltation

Eescent of the fetal head Fetal position

8terine contractions

this section of the paragraph has as its central feature a graph ofcervical diltation against time

it is divided into a latent phase and an active phase


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Active phase'

/ontractions at least : > != min

each lasting ; $= sceonds &he cervix should dilate at a rate of !

cm > hour or faster


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Alert line - health facility line%

&he alert line drawn from : cm diltation

represents the rate of diltation of ! cm >

hour Boving to the right or the alert line means

referral to hospital for extra vigilance


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Action line - hospital line%

&he action line is drawn $ hour to the right

of the alert line and parallel to it

&his is the critical line at which specific

management decisions must be made at the

hospital


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Eescent of the fetal head

It should be assessed by abdominal

examination immediately before doing

a vaginal examination0 using the rule of

fifth to assess engagement

&he rule of fifth means the palpable

fifth of the fetal head are felt by

abdominal examination to be above the

level of symphysis pubis

When ,># or less of fetal head is felt

above the level of symphysis pubis 0this means that the head is engage 0 and

by vaginal examination 0 the lowest

part of vertex has passed or is at the

level of ischial spines


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Assessing descent of the fetal head by vaginal

examinationG

= station is at the level of the ischial spine -)p%&


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8terine contractions

bservations of the contractions are made every hour in the

latent phase and every half4hour in the active phase

fre2uency how often are they felt

Assessed by number of contractions in a != minutes period

duration how long do they last Beasured in seconds from the time the contraction is first felt

abdominally 0 to the time the contraction phases off

5ach s2uare represents one contraction


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Palpate number o- contraction in ten

minutes and duration o- each contraction in

seconds

*ess than ,= seconds3

Detween ,= and $= seconds3

Bore than $= seconds3


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Banagement of labour using the

partograph


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4 latant phase is less than hours

4 progress in active phase remains

on or left of the alert line

Eo not augment with oxytocin iflatent and active phases go normally

Eo not intervene unless complications

develop

Artificial rupture of membranes

- A6B .

7o A6B in latent phase

A6B at any time in active phase


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Detween alert and action lines

In health center 0 the women must be transferred to a

hospital with facilities for cesarean section 0 unless the

cervix is almost fully dilated

bserve labor progress for short period before transfer

/ontinue routine observations

A6B may be performed if membranes are still intact


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At or beyond action line

/onduct full medical assessement

/onsider intravenous infusion > bladder catheterization > analgesia

ptions

4 Eeliver by cesarean section if there is fetal distress or obstructedlabour

4 Augment with oxytocin by intravenous infusion if there are no

contraindications


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AD76BA* P665)) F

*D6


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ne of the main functions of the partograph

is to detect early deviation from normal

progress of labor


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Boving to the right of alert line

&his means warning

&ransfer the woman from health center tohospital

reaching the action line

&his means possible danger Eecision needed on future management

-usually by obesteritian or resident .

P l d l h


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Prolonged latent phase

If a woman is admitted in labor

in the latent phase - less than :cm diltation . and remains in the

latent phase for next hours

Progress is abnormal and she

must br transferred to a hospital

for a decision about further

action

&his is why there is a heavy line

drawn on the partograph at the

end of hours of the latent phase

Polonged Active phase


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Polonged Active phase

In the active phase of labor 0 plotting ofcervical diltation will normally remain

on or to the left of the alert line Dut some cases will move to the right ofthe alert line and this warns that labormay be prolonged

&his will happen if the rate of cervical

diltation in the active phase of labor is not ! cm > hour or faster

A woman whose cervical diltationmoves to the right of the alert line must

be transferred and manged in a hospital

with ade2uate facilities for obstetricintervention unless delivery is near at the action line 0 the woman must be

carefully reassessed for why labor is notprogressing and a decision made onfurther management


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)econdary arrest of

cervical diltation

Abnormal progress of labor may

occur in cases with normal

progress of cervical diltation then

followed by secondary arrest ofdiltation

d f h d d


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)econdary arrest of head descant

Abnormal progress of labor may occur with normal progress ofdescent of the fetal head then followed by secondary arrest of

desscent of fetal head


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Precipitate *abour

4 Baximum slope of dilatation of # cm>hr or

more


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It is important to realize that the partograph is a tool for

managing labor progress only

&he partograph does not help to identify other ris1 factors

that may have been present before labor started


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only start a partograph when you have chec1ed that there are

no complications of pregnancy that re2uire immediate action

a partograph chart must only be started when a woman is in

labor044 be sure that she is contracting enough to start a

partograph

if progress of labor is satisfactory 0 the plotting of cervical

diltation will remain or to the left of the alert line


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when labor progress well 0 the diltation should not move to the

right of the alert line

the latent phase % = C : cm diltation 0 is accompanied by gradual

shortening of cervix % normally 0 the latent phase should not last

more than hours

the active phase 0 : C != cm diltation 0 should progress at rate of

at least ! cm>hour

when admission ta1es place in the active phase 0 the admission

diltation0 is immediately plotted on the alert line


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diltation of the cervix is plotted - recorded with an K 0 desent of thefetal head is plotted with an 0 and uterine contractions are plottedwith differential shading

desent of the head should always be assessed by abdominalexamination - by the rule of fifths felt above the pelvic brim .

immediately before doing a vaginal examination

assessing descent of the head assists in detecting progress of labor

increased molding with a high head is a sign of cephalopelvicdisproportion


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vaginal examination should be performed infre2uently as this is

compatible with safe practice - once every $ hours is

recommended .

when the woman arrives in the latent phase 0 time of admission

is = time

a woman whose cervical diltation moves to the right of the alert

line must be transferred and manged in an institution with

ade2uate facilities for obstetric intervention 0 unless delivery isnear


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when a woman 0s partograph reaches the action line 0 she must be

carefully reassessed to determine why there is lac1 of progress 0 and

a decision must be made on further management - usually by an

obesterician or resident .

when a woman in labor passes the latent phase in less than hours

i%e%0 transfers from latent to active phase 0 the most important featureis to transfer plotting of cervical diltation to the alert line using the

letters &60

*eaving the area between the transferred recording blan1% &hebro1en transfer line is not part of the process of labor

do not forget to transfer all other findings vertically


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IBP6&A7& /)IE56A&I7)

KL&/I7


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KL&/I7 xytocics must be preserved in a cool 0

dar1 place

A local regime may be used xytocin should be titrates againstuterine contractions and increased everyhalf4 hour until contractions are : or $in!= minutes 0 each lasting $= C #=seconds

It may br maintained at the rate thoughoutthe second stage of labor

)top oxytocin infusion if there isevidence of uterine hyperactivity and > orfetal distress

xytocin must be used with caution inmultiparous women and rarely 0 if at all 0in women of para $ or more

Augment with oxytocin only afterartificial rupture of membranes and

provided that the li2uor is clear


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F5&A* EI)&65))

If a woman is laboring in a health center % transfer her to a hospitalwith facilities for operative delivery

In a hospital 0 immediately 3

4 /onduct a vaginal examination to exclude cord prolapse and observe

amniotic fluid4 Provide ade2uate hydraion

4 Administer oxygen 0 if avaliablestop oxytocin

4&urn the woman or her left side

i i f l b


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Eiagnosis of labour

6egular painful contractions resulting

in progressive change of the cervix

>4 show

>4 rupture of membranes


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&he partograph in the management

of labor following cesarean section& In women undergoing a trial of labor following cesarean

section0 the partographic zone ,4: h after the alert line

represents a time of high ris1 of scar rupture% An action

line in this time zone would probably help reduce therupture rate without an unacceptable increase in the rate of

cesarean section


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5*5/&67I/ PA6&6APH

Full electronic capture of patienti f i d i hildbi h i l di


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information during childbirth including0

/&'s0

partograms0

all labour events0

outcome information0

fetal blood sampling results and cordblood gases direct from the blood gas

analyser&his information can be shown in real time

to enhance communication within andoutside the delivery suite to improve

patient care and reduce human error%

It can be accessed over the anywhere0anytime0 from within a hospital or from ahome%%


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&his system provides accurate continuous measurements of


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dilatation and station%

&he method is superior to digital examination and provides real

time diagnosis of non4progressive and precipitous labor%

&he system is li1ely to reduce discomfort and infections associated

to multiple vaginal examinations%%


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&he Fetal Bonitoring )ystemis a computer based training system that can be accessed over

the anywhere0 anytime0 from within a hospital or from a

home&


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