PARTOGRAPH • Legally, health care workers who are
I. The Partograph
• A tool for monitoring the progress of
labor
• Guides birth attendant to identify
women whose labor is delayed and
therefore decide appropriate action
• A partograph is a graphical record of
the observation made of a woman in
labor.
It is originally designed and used by Prof. R. H.
Philpott in 1972 and modified, developed and
extensively tested by the World Health
Organization (WHO).
In 1954, Friedman devised a partograph that
was based on observations of cervical
dilatation and fetal station against time
elapsed in hours in time of labor. The time
onset of labor was based on the patient’s
subjective perception of her contractility.
o In1972, Philpott and Castle
introduced the concept of “ALERT”
and “ACTION” lines. The alert line
represented the mean rate of
progress of the slowest 10% of
patients in African population whom
they served.
The alert line was shown at a slope of 1
centimeter/hr for nulliparous women starting
at zero time i.e.time of admission.
The action line was drawn four hours to the
right of the alert line. It shows that if the
patient has crossed the alert line, active
management should be instituted within 4
hours, enabling the transfer of the patient to
a specialized tertiary care center.
Who can use the partograph?
• Usually, a midwife is responsible for
recording the data on the progress of
labor on a partograph. However,
trained health workers including
nurses can also use a partograph.
What are the legal responsibilities of health
care workers using a partograph?
using the partograph should:
o Provide correct entries
o Analyze and interpret findings
correctly
o Record comprehensive data
o Truthfully record assessment data
o Observe and monitor clients
accordingly
o Gather assessment data on time
o Refer clients appropriately when
abnormalities are noted
o Act on abnormalities noted in the
recordings
o Prevent further development of
abnormalities noted in the recordings
o Have a thorough understanding of the
implications of assessment findings
General Purpose of a partograph
1. In general, a partograph enables health
care workers to detect abnormalities,
potential problems and possible
augmentation of labor by facilitating the
assessment and monitoring:
a. The pregnant client
b. The labor process
c. The fetus
2. Early detection of abnormal progress of
labor.
3. Prevention of prolonged labor.
4. Recognize cephalopelvic disproportion long
before obstructed labor.
5. Assist in early decision on transfer,
augmentation, or termination of labor.
6. Increase the quality and regularity of all
observations of mother and fetus.
7. Early recognition of maternal or fetal
problems.
8. Reduction of complications from prolonged
labor for the mother (postpartum
hemorrhage, sepsis, uterine rupture and its
sequence0 for the newborn (death, anoxia,
infections etc.).
Advantages of using partograph:
1. Facilitates the assessment of labor,
enabling health care workers to see the
progress of labor at a glance.
2. Facilitates decision making of health care
provider for prompt referral of clients thereby
reducing the number of prolonged labors,
oxytocin augmentation and caesarian
delivery.
3. Reduces maternal mortality and morbidity
related to obstructed labor.
Assessment Method and equipment when
using partograph:
Assessment Method: PALPATION
vvvEquipment:
▪ stethoscope – to auscultate the FHR
towards the end of the uterine
contraction to detect slow recovery
of the FHR back to baseline
▪ Handheld Doppler – to detect the
FHR all throughout the contraction
especially during the contraction
when the use of stethoscope
becomes uncomfortable
▪ Cardiotograph machine – to provide
a graphic record of the response of
the fetal heart rate to uterine activity
including information on fetal heart
rate and variability
COMPONENTS of a Partograph
1. The fetal record: data to be entered
on the fetal record
2. The record of the progress of labor:
data entered are a) cervical dilatation,
b) descent, c) uterine contractions
Cervical dilatation- represented by
vertical scale 0-10
3. The maternal record
1. FETAL HEART RATE– represented by
vertical graph with small squares
labeled 100 to 180 at intervals of 10.
• Assess the FHR before any of the
following is done: a) artificial rupture
of membrane b) administration of
anesthesia, c) administration of
medication
• Assess after any of the following
conditions: a) abnormal uterine
contraction, b) rupture of
membranes, c) peak time of
medication, d) administration of
oxytocin
FHR – to be taken over a complete
minute
auscultate every hour
during latent phase, every
30 minutes during active
phase, every 15 minutes
every fetal distress
Auscultation of the FHR must be made
before and during the 30 seconds after a
contraction, in order to assess decelerations.
Decelerations – are slowing of the
fetal heart rate below 120 beats per min
LIQOUR– refers to the condition of the
amniotic fluid
Clear – normal; greenish – indicates
meconium stained; muddy yellow color or
slightly greenish- indicate a previous
event from which the fetus has recovered,
this is common and has no significance in post
term babies.
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
MOULDING– refers to the overlapping of
cranial bones. This means that the spaces
between the cranial bones are palpable.
0 – separated bones, sutures are
felt easily
+ - bones just touching each other
++ - overlapping bones (reducible)
 +++ - severely overlapping bones
(non- palpable)
What are the indicators of the need for
further interventions by the health worker, as
reflected on the fetal record?
Late deceleration – indicate placental
insufficiency. Placing the client on the
left lateral recumbent position and
administration of oxygen are the
priority interventions.
Variable deceleration – may indicate
cord compression. Place the client on
the left lateral recumbent position
and administration of oxygen are the
priority interventions.
Increasing molding with the head
high in the pelvis, which is an
ominous sign of cephalopelvic
disproportion
A greenish liquor in a non-breech
presentation which indicates
meconium staining, a sign of fetal
distress.
2. The record of the progress of labor:
data entered are
a) cervical dilatation
b) descent
c) uterine contractions
Cervical dilatation- represented by
vertical scale 0-10
3. The maternal record
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
II. Recording the findings in the partograph a
rate of ≥ 1 cm/hour.
•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 (4cm
or more) and is contracting adequately (3-4
contractions in 10 min)
Start plotting on alert line in the intersection
corresponding cervical dilatation finding
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
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
Connect the “X”s to demonstrate the pattern
of labor
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 labor
•Obvious obstructed labor
III. Distinguishing normal from abnormal
labor pattern
Progress of labor is normal if plotting stays on
or to the left of the alert line (green part)
Note that based on the structure of the
partograph has soon as 4 cm is reached the
cervix should dilate normally at a rate of ≥ 1
cm/hour
• Start when woman is in ACTIVE
LABOR (4 cm or more) and is
contracting adequately (3-4
contractions in 10 minutes)
• 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 partograph passes ALERT LINE • Cervical dilation plotted as ‘X’
•Reassess woman and consider referral. • Infrequent vaginal examination
•Alert transport services. (every 4hrs) dilation moves to the
•Monitor intensively. right of the Alert line must be
transferred for obstetric
If partograph passes action line, refer interventions
urgently to an EmONC facility unless • A woman whose cervical moves to
imminent delivery. the right of the alert line must be
transferred for obstetric
MATERNAL AND FETAL WELL BEING interventions
IV. Other findings to note (and record) during
Internal examination
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 10minute period
Other findings:
Delivery of Placenta (Time)
Oxytocin (Time given)

Other problems:
If woman is admitted in LATENT PHASE of
labor –record only other findings (BP,
FHTetc).
If she remains in latent phase for next 8
hours (labor is prolonged), transfer her to
hospital.
Quick action warranted in labor during
following conditions
-Delay in cervical dilatation
-FHR < 120 or > 160/mt on 3 observations
-ROM and meconium- stained liquor or
absence

Points to remember while using Partograph

• It is only a tool for managing labor
progress
• Only start partograph who don’t
have complications and doesn't
require Referral
• Only be started when a woman is in
labor
• If progress of labor is satisfactory, the
plotting remains on/to the left of the
Alert line