The Partogram

Dr. C. Savona-Ventura
MD, DScMed, FRCOG, Accr.Cert.OG, MRCP

The Partogram
A graphic representation of the progress of labour
Cervicograph Descent of Head [cf moulding] Uterine contractions Features that assist progress [membranes/augmentation/drugs] Maternal condition [heart rate, BP, urinalysis] Fetal condition [heart rate, liquor]

Phases in progress of Labour

LATENT PHASE: Nullipara 8.6-20.6 hrs Multipara 5.3-13.6 hrs

ACTIVE PHASE: Acceleration Phase ] 4.9-11.7 hrs Phase of Maximum Slope ] Deceleration Phase 54 min-3.3 hrs
2.2-5.2 hrs

14 -53 min 18 -50 min

SECOND STAGE THIRD STAGE

57 min-2.5 hrs

up to 20 min

Labour progress - cervical

dilatation

10 8 6 4 2 0 0 5 10

2nd Stage 1st Stage of Labour LATENT PHASE

1 cm/hr

ACTIVE PHASE
15 20

Latent Phase
Poor rate of cervical dilatation but general preparation of cervix. Duration: Nullipara Multipara
8.6-20.6 hrs 5.3-13.6 hrs

Assessed using Bishop Score 0

Cervical dilatation Cervical effacement [%] [cm] 0 0-40 3 Post Firm -3

1
1-2 40-60 2 Mid Mod -2

2
3-4 60-80 1 Ant Soft -1,0

3
5-6+ 80+ 0

Cervical position Cervical consistency Station re ischial spine [cm]

+1,+2

The use of the partogram during the latent phase not of use since this would chart only cervical dilatation. We should use a cervicograph.

Prolonged Latent Phase

Definition
>20 hrs [nullipara]; >14 hrs [multipara]

Aetiology
Excessive sedation Unfavourable Cervix Idiopathic [forced induction] False Labour

Outcome
14% will go into a Protracted Active Phase

Prolonged Latent Phase

Management
DIAGNOSIS EVALUATE CAUSE THERAPEUTIC REST No Change Membranes ruptured Progress to Active Phase Augmentation False Labour Membranes Intact

Active Phase
Good rate of cervical dilatation; cervix fully effaced. Nullipara Multipara Lower limit of Normal Rate:
~3.0 cm/hr ~5.7 cm/hr ~1.0 cm/hr

The use of the partogram during the active phase is essential for good intrapartum management Draw ALERT & ACTION LINES at onset of active phase
At 2-3 cm dilatation with patient getting strong and regular contractions. Slope at 1cm/hr; lines four hours apart

Partogram - cervical dilatation

10 9 8 7 6 5 4 3 2 1 0 TIME CERVICAL DILATATION

ALERT LINE

ACTION LINE

Uterine contractions
Aim at:- strong & regular contractions
ASSESS DURATION OF CONTRACTION
mild <20 sec moderate 20-40 sec strong >40 sec

ASSESS FREQUENCY OF CONTRATIONS

Number of contractions in last 10 min of each hr. increased frequency from 1:10 to 5:10 minutes

Descent of head in fifths per

abdomen

Engagement at 2/5 and less If 3/5 or more than CPD [absolute or relative] is present

Vaginal assessment in relation to ischial spines not useful to define engagement since position of spines dependant on type of pelvis.

Prolonged Active Phase

Definition
>6 hrs or >1.2 cm/hr [nullipara]; >5.2 hrs or >1.5 cm/hr [multipara]

Aetiology
CephaloPelvic Disproportion [often relative] Fetal head malposition: OP/OT Idiopathic [early ARM] Excessive sedation

Outcome
39% Po & 13% P1+ will go into Secondary Arrest

Prolonged Active Phase

10 9 8 7 6 5 4 3 2 1 0 TIME CERVICAL DILATATION

ALERT LINE NORM AL DYSFUNCTIONAL ACTION LINE

Prolonged Active Phase

Management
DIAGNOSIS EVALUATE CAUSE

HYPOTONIA Augment

HYPERTONIA Augmented? CPD

Normal Progress Vaginal Delivery

Reduce Dose 2o Arrest

LSCS

Secondary Arrest of Active Phase

Definition
No change in cervical dilatation over a period of 2hrs+. Cervix becomes oedematous. Can occur at 4-7 cm dilatation or as a protracted Deceleration phase

Aetiology
CephaloPelvic Disproportion [often absolute] Fetal head malposition [OP/OT] or Malpresentation [breech] Insufficient uterine action Excessive sedation

Outcome
Will require LSCS. If protracted deceleration beware of shoulder impaction

Partogram - cervical dilatation

10 9 8 7 6 5 4 3 2 1 0 TIME CERVICAL DILATATION

ALERT LINE NORM AL 2 ARREST PROTRACTED ACTION LINE

Secondary Arrest of Active Phase

Management
DIAGNOSIS EVALUATE CAUSE No CPD
head 2/5-

CPD
head 3/5+

Assess Uterine Activity Optimal

head 2/5

Sub-Optimal Augment

LSCS
No Response

Good Response Vaginal Delivery