Partograph

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Introduction:

• 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 and fetus
• It was developed and extensively tested by WHO
• Friedman’s partogram devised in 1954 was based on observations of cervical dilatation and fetal station against time elapsed in hours from onset of labour. The time onset of labour was based on the patient’s subjective perception of her contractility. Plotting cervical dilatation against time yielded the typical sigmoid or ‘S’ shaped curve station against time gave rise to hyperbolic curve.
• The partograph can be used by health workers with adequate training in midwifery who are able to:

o   Observe and conduct normal labour and delivery

o   Perform vaginal examination in labour and assess cervical dilatation accurately

o   Plot cervical dilatation accurately on a graph against time

• There 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, the partograph must be accompanied by a partogram of training in its use and by appropriate supervision and follow up

Objectives:

• 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, augmentation or termination of labour
• Increase the quality 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 from prolonged labour for the mother (postpartum hemorrhage, sepsis, uterine rupture and its sequelae) and for the newborn (death, anoxia, infections, etc) 

Functions:

• The partograph is designed for use in all maternity settings, but has a different level of function at different levels of health care
• In health center, the partograph’s critical function is to give early warning if labour is likely to be prolonged and to indicate that the woman should be transferred to hospital (ALERT LINE Function)
• In hospital settings, moving to the right of alert line serves as warning for extra vigilance, but the action line is the critical point at which specific management decisions must be made
• Other observations on the progress of labour are also recorded on the partograph and are essential features in management of labour

Components:

The partograph can be divided into three parts:

• Part 1: Fetal Condition (top)
• Part 2: Progress of labour (middle)
• Part 3: Maternal Condition (bottom)

Outcomes:

[A] Part 1: Fetal Condition

This part of the graph is used to monitor and assess fetal condition:

• Fetal heart rate
• Membranes and liquor
• Moulding of the fetal skull bones

Fetal heart rate	Membrane & Liquor		Moulding of fetal skull bones
(1) Basal fetal heart rate >160 bpm = tachycardia <120 bpm = bradycardia <100 bpm = severe bradycardia	I	Intact Membranes	0	Separated bones, suture felt easily
	C	Rupture membranes + clear liquor	+	Bones just touching each other
	M	Rupture membranes + meconium-stained liquor	++	Overlapping bones (reducible)
(2) Deceleration Yes or No
	B	Rupture membranes + blood-stained liquor	+++	Severely overlapping bones (non-reducible)
(3) Relation to contraction Early Variable Late
	A	Rupture membranes + absent of liquor	↑ molding with head high in pelvis is an ominous sign of cephalopelvic disproportion

[B] Part 2: Progress of Labour

This section of the graph has its central feature; a graph of cervical dilatation against time, use to assess the following:

• Cervical dilatation
• Descent of fetal head
• Fetal position
• Uterine contractions

It is divided into a latent phase and active phase:

Latent phase:	Active phase:
It starts from onset of labour until the cervix reaches 3 cm dilatation	Once 3 cm dilatation reached, labour enters the active phase
Lasts 8 hours or less	The cervix should dilate at a rate of 1 cm/h or faster
Contractions at least 2/10 min	Contractions at least 3/10 min
Each lasting < 20 seconds	Each lasting <40 seconds

Alert Line (health facility line)

• The alert line drawn from 3 cm dilatation represents the rate of dilatation of 1 cm/hour
• Moving to the right or the alert line means referral to hospital for extra vigilance

Action Line (hospital facility line)

• The action line drawn 4 hours to the right of the alert line and parallel to it
• This is critical line at which specific management decisions must be made at the hospital

[C] Part 3: Maternal Condition

• Name / DOB / Gestation
• Medical / Obstetrical issues
• Assess maternal condition regularly by monitoring:

o   Drugs, IV fluids 7 oxytocin, if labour is augmented   

o  Pulse, blood pressure  

o  Temperature  

o  Urine volume, analysis for protein & acetone

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