PARTOGRAPH FORM

PATIENT’S NAME (LAST, FIRST, MIDDLE) DATE OF BIRTH AGE SEX HEIGHT CIVIL STATUS
 MALE ___________cm
WEIGHT
 FEMALE ___________kg
ATTENDING PHYSICIAN MRN NATIONALITY ROOM / BED NO.

PIN

10 cm

*Start on the alert line 9 cm

*Mark "X" for Cervical Dilatation

Initial Examination: If NOT NORMAL, REFER. 8 cm

Normal means Cephalic, Longitudinal, Singleton and >37 weeks
Presentation 7 cm
Lie
Number of Fetus 6 cm
AOG
*Record Time over the Line Corresponding to cervical dilatation. 5 cm

4 cm
FINDINGS: 1 2 3 4 5 6 7 8 9 10 11 12
TIME
Cervical dilatation (cm)
Hours since Ruptured Membranes (Time of the Rupture):
Amniotic Fluid
Vaginal Bleeding (0 / + / + +)
Fetal descent
Contractions in 10 minutes
Fetal Heart Rate (120-160/min is normal)
Temperature
Pulse (beats/minute)
Blood pressure (systolic/diastolic)
Urine Voided (Yes/No)
Delivery of the newborn (time)
Oxytocin (doses & time given)
Delivery of placenta (time)
Problem - onset/description

Management

_________________________________

Name and signature of Nurse-on-duty