• • • • • •

Introduction Development of the Partograph The WHO Partograph Labour management with the Partograph The U.P.T.H. Partograph Conclusion.

Partograph is a graphical method of recording the events in labour. This is displayed for easy and quick assessment of labour progress and timing of management decisions. 585,000 women all over the world die annually due to complications of pregnancy and child birth, 90% of them occurring in developing countries of Africa and Asia. 10 – 12% of these deaths are due to prolonged and obstructed labour and it’s complications such as sepsis, dehydration and uterine rupture. Most of these deaths are preventable. It is in a bid to predict and identify labours that may be prolonged that the partograph was designed.

The first man to observe the progress of cervical dilatation in labour and plot it against time was Friedman in 1955. This is the cervicograph. He applied his cervicograph to the clinical management of labour .

FRIEDMAN’S CERVICOGRAPH Cervical dilatation in cm • • • Fetal heart rate monitoring •

10 9 8 7 6 5 4 3 2 1

It was not until 1972 that Philpott and3 Castle working6 in the Southern African states of 1 2 4 5 7 8 9 10 Zimbabwe and Malawi, designed the modern composite Partograph. Time in hours Central to the Philpott Partograph are: The Cervicograph incorporating the alert line and the action line. Fetal heart rate tracing for Fetal monitoring Tracing for assessing Maternal Vital Signs Columns for monitoring of quality of uterine contractions and colour of liquor. THE PHILPOTT PARTOGRAPH (1)

200 180 160

140 120 100 0

Time in hours

24 hrs

THE PHILPOTT PARTOGRAPH (2) Cervical dilatation in cm

9 7 6 5 4 3 2 1

Philpott was the0 first person to incorporate the concept of alert line and action line to predict 6

Action Line


Alert Line

abnormal labours. The tool was used extensively in labour management in Malawi and Zimbabwe with very interesting results.

24 hrs

The World Health Organisation as part of her safe motherhood initiative aimed at reducing maternal mortality and morbidity designed the WHO Partograph in 1988 and recommended it for labour management in developing countries especially in peripheral health centres. This was essentially a modification of the Philpott Partograph. Essential features include:• • A Cervicograph which comprises the latent and active phase of labour and incorporate the action and alert lines in the active phase. Columns for fetal and maternal monitoring and that of quality of Uterine contractions as in the Philpott Partograph

THE WHO PARTOGRAPH Cervical dilatation in cm


10 9 8 7 6 5 4 3 2 1

Active Phase Alert Line Latent Phase

4 8 12 16 20 24 A prudent application of the WHO Partograph in peripheral centres will result in early referrals

to a central unit for abnormal labours in which the Cervicogram crosses to the right side of the Time in hours alert line. A multicentre trial by the WHO using over 35,000 parturients showed very impressive results in terms of labour outcome, Caeserean Section rate and duration of labour .

This is basically a modification of the Philpott Partograph but does not have a predetermined alert and action lines as these are usually individualized. Moreover, progress of labour are charted and visualized and management decisions are appropriately timed. In the U.P.T.H Partograph, there are also no allowance for the latent phase of labour as only parturients in the active phase are put on a Partograph.

Action Line

The aim of managing labour with a Partograph is to predict and prevent prolonged labour and obstructed labour and hence its complications. This is done by observing the rate of labour progress using the most objective index which is Cervical dilatation; plotted against time, and to a lesser extent the rate of descent of the presenting part. These observation will assist in timing management decisions. The work of Philpott et al have a Cervical dilatation rate of 1cm / hour as the least rate of progress in a normal parturient in active phase of labour. Any labour that progresses at any rate less than this needs reassessment and some form of intervention to ensure normal progress. Using the Partograph, the following are done:• • • • • Parturients are admitted into labour ward and put on a Partograph once labour is diagnosed, and vaginal examination done 4 hourly. The latent phase of labour should not last beyond 8 hours. In the active phase of labour, cervical dilatation of > 1 cm / hour is expected. Quality of uterine contractions, fetal heart rate monitoring and maternal vital signs monitoring are evaluated. The parturient is transferred from a peripheral unit to a central unit if there is a prolonged latent phase or if active phase labour is progressing at less than 1 cm / hour i.e. if cervicogram falls to the right of the alert line. • At the central unit, reassessment is made and interventions as appropriate carried out in terms of rupture of membranes, rehydration, antibiotics, analgesia, caesarean section as the case may be .

Using the Partogram, many workers including Philpott, Bird and O’ Driscoll etc have reported impressive results including reduction in prolonged and obstructed labour, Fetal distress in labour, Caesarean section rate and an improved outcome in labour. Philpott working in Zimbabwe reported

• • •

Reduction in prolonged labour from 13% to 0.6%. Reduction in Perinatal mortality from 5.8% to 0.6%. Reduction in Caesarean section from 9.9% to 2.6%.

There were concurrent reduction in primary PPH, Puerperal Sepsis and improved Apgar score of babies.

The Partograph is a simple tool that is easy to learn and use, saves cost, reduces operative delivery and improves outcome for mother and baby. It should not only be embraced but be recommended to Peripheral health centres to improve labour outcome and reduces our alarming maternal mortality ratio in this country.

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