The Partograph

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

Fetal well-being

Progress of labor

Maternal well-being

Conditions that do not need

the use of partograph
Antepartum

hemorrhage Multiple pregnancy

Severe pre-eclampsia
Malpresentation
and eclampsia
Very premature baby
Fetal distress
Obvious obstructed
Previous cesarean
labor
section

HOW TO USE THE PARTOGRAPH

A partograph should be started when a
woman is in active labor (cervix dilated 4
cm or more)

If there are any complications that require

immediate attention take appropriate
actions before starting partograph

II. Recording the findings

in the partograph
Start

by labeling the record with

pertinent patient identifying
information.

HOW TO USE THE PARTOGRAPH

Personal Information

HOW TO USE THE PARTOGRAPH

Fetal Heart Rate
Every
vertical side
of the
rectangle:
10 beats per
minute

Every
horizontal
side of the
rectangle:
30 minutes

Severe Tachycardia

Severe Bradycardia

The heart rate of less than 100 or more than 180

beats per minute requires immediate action

HOW TO USE THE PARTOGRAPH

Fetal Heart Rate
Severe Tachycardia

Severe Bradycardia
Plot FHR using a dot

HOW TO USE THE PARTOGRAPH

Amniotic Fluid

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

HOW TO USE THE PARTOGRAPH

Moulding

O: Bones are separated and the sutures can be felt easily

+: Bones are just touching each other

++: Bones are overlapping
+++: Bones are overlapping severely

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

HOW TO USE THE PARTOGRAPH

Moulding

O: Bones are separated and the sutures can be felt easily

+: Bones are just touching each other

++: Bones are overlapping
+++: Bones are overlapping severely

HOW TO USE THE PARTOGRAPH

Cervical Dilatation
Every vertical
side of the
rectangle: 1 cm
of dilatation

Every horizontal
side of the small
rectangle: 30
minutes

Alert line represents

the rate of cervical
dilatation 1 cm per
hour which is
considered to be the

HOW TO USE THE PARTOGRAPH

Cervical Dilatation
Alert line represents
the rate of cervical
dilatation 1 cm per
hour which is
considered to be the
lowest level of the
norm for both
nullipara and
multipara

Alert line

D
I
L
A
T
A
T
I
O
N

Alert line

D
I
L
A
T
A
T
I
O
N

Action line

Parallel and
4 hours to
the right
of alert line

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)

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

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

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

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

4pm

8pm

10pm

Connect the Xs to demonstrate

the pattern of labor

EXAMPLE

A G1P0 is being monitored by a

midwife at home. Her initial IE at
1 am showed 4 cm dilated cervix.

EXAMPLE

At 5 am, another IE showed 8

cm dilated cervix.

EXAMPLE

At 7 am, the patient is 9 cm

dilated, station -1, intact BOW.

III. Distinguishing normal

from abnormal labor pattern

Progress of
labor is
normal if
plotting
stays on or
to the left
of the alert
line

6pm

8pm

4pm

10pm

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.

Plotting that
passes the
alert line
more so if
it reaches
or passes
the action
line
indicates
abnormal
progress of
labor

X
X
X

4pm

6pm

8pm

10pm

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

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

Descent of the Head

Descent of the Head

Plot the descent of the head

using the mark 0

Example:
Descent of
the head is
5/5

After 4
hours, the
descent of
the head is
2/5

Connect
the Os

Counting Contractions

Counting Contractions

Contraction: 2 contractions/ 10 minutes

Duration: 45 seconds each

Counting Contractions

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
Indicate

whether the progress of

labor in the following partographs
are normal or abnormal.

Case 1

10pm

2am

Case 2

8pm

2am

4am

12mn

X
X

Case 3

9pm

1am

3am

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

REFERENCES
Managing Prolonged and Obstructed
Labour. Education for Safe Motherhood.
WHO, 2006.
IMPAC, WHO.
MDG Modules, WHO