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The partograph is a useful tool for monitoring the progress of labor. Use it to avoid
unnecessary interventions so maternal and neonatal morbidity are not needlessly
increased, to intervene in a timely manner to avoid maternal and neonatal morbidity
or mortality and to ensure close monitoring of the woman in labor.

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The WHO has come out with 3 versions of the partograph

1. Composite partograph was based on the ffg principles:

2. The MODIFIED PARTOGRAPH was introduced in 2000

. Latent phase was removed

• Active phase – starts at 4 cm. Many mulitparous women have patulous cervix with
dilatations of up to 3 cm even before onset of labor. However, most women are in
active labor by 4cm Cervical dilatation .

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This is the SIMPLIFIED PARTOGRAPH which is recommended for use in BEMONC

/Level I facilities.
Color codes: green – normal; yellow – alert; red – emergency
• Action and alert lines are not drawn but the area for recording cervical dilatation is
divided into three. The area in green corresponds to the area to the left of the
standard alert line indicating that labor is progressing normally. The area in red
corresponds to the area to the right of the standard action line indicating that
labor is dangerously slow. The area in yellow corresponds to the area between the
standard alert and action lines and indicates the need for caution regarding
progress of labor.
• Descent of the head and other variables are not recorded in this partograph. Fetal
head descent usually occurs late in first stage and in second stage. Plotting of fetal
head descent may not contribute to monitoring progress in the 1 st stage of labor.
Hence this is not included in the simplified partograph.

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The partograph has two parts.

The upper colored portion is where you plot the progress of labor.

The lower portion is where you are supposed to write your other observations
particularly the findings of your monitoring of the maternal and fetal well-being.

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Let us enlarge the upper portion of the partograph. As you can see it is divided evenly
into small boxes by gridlines vertically and horizontally.
Each horizontal gridline corresponds to the cervical dilatation in centimeter from 4 to
10.
While the vertical gridlines indicate the time, in hours, the patient is in active labor.
The upper portion is also divided into 3 colors – green, yellow, and red.
The boundary between the green and yellow parts forms a diagonal line which is
highlighted here. This is designated as the alert line which starts at 4 cm. up to 10 cm.

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Parallel and 4 hours to the right of the alert line is another line formed by the
boundary between the yellow and red part which is again highlighted here. This is the
action line. Note that it too starts at 4 cm and ends in 10 cm.

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The partograph need not be used in all pregnant or laboring patients especially those
who are for cesarean delivery like those with malpresenting babies (breech or
transverse lie), those with scarred uteri, those with antepartum hemorrhage (like
placenta previa). It is also not needed in those who have to be delivered immediately
because of fetal distress or those with severe uncontrolled pre-eclampsia and
eclampsia. Likewise it may not be appropriate for those with twins or very premature
baby.

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Write the name, age, gravidity and parity

Date and Time of admission

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You do not always have to start the plotting in the Y axis (4 cm line) since not all
patients are first seen at this cervical dilatation. If the patient arrives at 6 cm cervical
dilatation start plotting in the 6 cm line but still in the alert line.

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If she is first seen at 8 cm, then start at the 8 cm line but still on the alert line.

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After indicating the time of first examination, proceed to indicate the time
consecutively in the next spaces.

* Note: TIME refers to the actual time the patient was admitted while the numbers in
the next row indicate the number of HOURS IN ACTIVE LABOR.

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Encourage audience participation.

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Intervention between alert and action lines:

In a health centre: the woman must be transferred to hospital with facilities for
caesarean section, unless the cervix is almost fully dilated.
Consider IV fluids, bladder catheterization, analgesia.
Artificial rupture of membranes (ARM) may be performed if the membranes are still
intact, and observe labour progress for a short period of time before transfer.
• In hospital: perform ARM if membranes intact, and continue routine observations.

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CEmOC facility is a hospital with capability for cesarean section.

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Aside from recording the progress of labor (in the upper colored portion), the
partograph is also useful for recording maternal and fetal well being (in the lower part
of the partograph)

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TIME refers to the actual time the patient was admitted. As previously mentioned,
write the TIME that the patient was admitted ON THE VERTICAL LINE and not on the
space after it.

The numbers in the next row indicate the number of hours the patient is in active
labor. Hence a patient who was admitted at 5 cm cervical dilatation is 2 hours in
active labor.

The next line is for the number of hours since ruptured membranes. Antibiotics are
started when the BOW has been ruptured 18 hours or more.

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Next do RAPID ASSESSMENT – look for danger signs

Is there vaginal bleeding? Any vaginal bleeding in
Observe uterine contractions hourly – record the number of contractions in 10
minutes.

If an abnormal heart rate is heard, listen every 15 minutes for at least 1 minute
immediately after a contraction. If the heart rate remains abnormal over 3
observations, action should be taken unless delivery is very close.
A heartbeat of 100 or lower indicates very severe distress and action should be taken
at once.

If there is thick meconium at any time or absent liquor at the time of membrane
rupture, listen to the fetal heart more frequently, as these may be signs of fetal
distress.

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Encourage the woman to void every 2-4 hours. Indicate if patient voided – Yes or No.
Check the axillary temperature every 4 hours.
Pulse Rate in one minute should be recorded every 30 minutes.
Check BP every 4 hours and record on the partograph.

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Normal

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Abnormal
Ask:
When should the patient be referred?

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Give the participants 3-5 minutes to answer this exercise.

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Ask: Is labor normal or abnormal?

Answer: abnormal labor (protracted active phase) although she delivered
spontaneously.

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Give the participants 3-5 minutes to answer this exercise.

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Check the answers individually.

Ask the participants – “Is labor normal or abnormal”? NOTE : Patient delivered
vaginally but labor is abnormal (protracted active phase of labor)

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Give the participants 3-5 minutes to answer this exercise.

Ask: What should be recorded on the partograph?
Note: The woman is not in active labor. Record only her name, G-P, date of
admission.
not the cervical dilatation. Vital signs should be noted in the LABOR RECORD.

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Check the answers individually.

Is labor normal or abnormal? Labor is ABNORMAL
When should the patient be referred? If the patient is in a Level I facility, patient
should have been referred at 9pm.

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Give the participants 3-5 minutes to answer this exercise.

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Check the answers individually.

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The partograph allows the care provider to objectively measure progress in labor and
maternal and fetal well-being.
If progress is satisfactory, this information can be used to reassure the woman and
her family.
If labor is progressing slowly, the care provider can initiate certain interventions to
prevent labor from being prolonged or obstructed.
Use of the partograph along with appropriate and timely interventions will reduce the
risk of prolonged labor to the mother and her fetus.

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