Made Easy

PARTOGRAPH

Source : Basic Emergency Obstetric Care

Dr. Jose Fabella Memorial Hospital, & WHO

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

OBJECTIVES

I. To understand the concept of the WHO partograph

To explain to mothers the significance of the graph

II. To record the observations accurately on the graph

III. To interpret the recorded findings, recognize deviation from the norm, and decide on timely referral

Monitor during labor…•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

DILATATION

Alert line Action line

DILATATION

Parallel and 4 hours to the right of alert line

Conditions that does 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

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)

X

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

X

X

X4pm

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

X

X

X

4pm 8pm 10pm

Connect the “X”s to demonstrate the pattern of labor

1am

EXAMPLE

A G1P0 is being monitored by a midwife at home. Her initial IE at 1 am showed 4

cm dilated cervix.

x

1am 5am

x

x

EXAMPLE

At 5 am, another IE showed 8 cm dilated cervix.

1am 5am

x

x

EXAMPLE

At 7 am, the patient is 9 cm dilated, station -1, intact BOW.

7am

x

III. Distinguishing normal fromabnormal labor

pattern

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

X

X

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.

X

X

4pm 6pm 8pm 10pm

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

X

12am 2am

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

What to do if partograph passes alert line •Reassess woman and consider criteria for referral.

•Alert transport services. •Empty bladder. •Ensure adequate hydration but omit solid foods.

•Encourage upright position and walking if woman wishes.

•Monitor intensively. If referral long, reassess in 2 hours and refer if no progress.

If partograph passes action line, refer urgently to an EmOC facility unless imminent delivery.

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

THE PARTS OF THE PARTOGRAPH

Progress of labor

Maternal and fetal well-being

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

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.

EXERCISES

EXERCISE

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

x

2am

x

10pm

Case 1

X

X8pm 12mn 2am

X

4am

X

Case 2

x

X

X

9pm 1am 3am

Case 3

EXERCISES

•Plot the observations in the following cases.

Case 4:A G2P1 was admitted at 2 am, IE showed a 4cm dilated cervix. The patient was still smiling and she was hesitant to be admitted.

At 6 am, another IE was done … 8 cm dilated cervix, 80% effaced, station 0.

At 8 am, fetal head was bulging at the perineum.

X2am 6am

X

X

8am

Answer to case 4

Case 5: A G4P2 was referred at 5 pm. The midwife said that the patient is at 4 cm cervical dilatation. At 9 pm, your IE showed 6 cm dilated cervix. At 1 am, another IE done showed 8 cm dilated cervix, 50% effaced, station -1, intact BOW.

X5pm

9pm

X

1am

X

Answer to case 5

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