STAGES OF LABOR & DELIVERY

PARTOGRAPH
Graphical presentation of the progress of
labor, fetal and maternal condition during
labor.

Tool to help detect whether labor is

progressing normally or abnormally

recording starts when the labor is in

ACTIVE PHASE (4 cm or above).
 OBJECTIVES
1.Early detection of abnormal progress of
a labor and Prevention of prolonged labor

2.Early recognition of maternal or fetal

problems

3.Recognize cephalopelvic disproportion

long before obstructed labor

4.Assist in early decision on transfer or

augmentation of labor
 IDENTIFICATION SECTION
❑ Name
❑ Gravidity
❑ Parity
❑ Hospital Number
❑ Date of Admission
❑ Time of Admission
❑ Rupture Membranes
COMPONENTS OF THE PARTOGRAPH

Part 1 • Fetal Condition (Top)

Part 2 • Progress Of Labor (Middle)

Part 3 • Maternal Condition (Bottom)

PARTOGRAPH
 PART 1
FETAL CONDITION
Part 1 : FETAL CONDITION
Fetal heart rate

Membranes and Amniotic

Fluid

Molding of the fetal skull

bones

Fetal Descent
 FETAL HEART RATE

Recorded initially and then

every 30 minutes.

The scale for fetal heart rate

covers the range from 80 to
200 beats per minute.
 FETAL HEART RATE

Indicator of fetal distress

Normal term HR (37 weeks and more) = 120–160 beats/minute.

Signs of fetal distress during labor :

• fetal bradycardia : FHR < 120 beats/minute for 10 minutes or more

• fetal tachycardia : FHR > 160 beats/minute for 10 minutes or more
 RECORDING FETAL HEART RATE
FHR RECORDED :
• every half hour(30minutes) in
the first stage of labor (if
every count is within the
normal range)
• every 5 minutes in the second
stage.
COUNT THE FETAL HEART
RATE:
• every five(5) minutes if the
amniotic fluid contains thick
green or black meconium.
• Whenever the fetal
membranes rupture, for
possible cord prolapse, cord
compression, or abruptio
placenta as the amniotic fluid
gushes out.
 AMNIOTIC FLUID
Intact Membranes …………………………..............................I
Ruptured Membranes + Clear Amniotic Fluid …………………..C

Ruptured Membranes + Meconium- Stained Amniotic Fluid……..M

Ruptured Membranes + Blood – Stained Amniotic Fluid ………..B

Ruptured Membranes + Absent Amniotic Fluid …………………A

Note:
• if the fetal membranes have ruptured, you should record the color of the fluid
initially and every 4 hours.
 MOLDING
The extent to which the bones of the fetal
skull are overlapping each other as the
fetal head is forced down the birth canal

Important indicator of how adequate the

pelvis can accommodate the fetal head

Assess the degree of moulding

initially and every 4 hours
ASSESSING MOLDING AND CAPUT FORMATION
Normal variations in Molding of the newborn
skull, which usually disappears within 1–3 days
after the birth.
A caput (swelling) of the fetal skull is normal if it
develops centrally, but not if it is displaced to one side.
CAPUT SUCCEDANEUM CEPHALOHEMATOMA
 RECORDING MOLDING
Bones are separated; sutures can be felt easily 0
Sutures apposed or just touching each other +1
Sutures overlapping but reducible +2
Sutures severely overlapping, not reducible +3
 FETAL HEAD DESCENT
Record of how far down the
birth canal the fetal head has
progressed.

Descent is plotted with an “O”

as symbol

Done initially and every 4

hours
FETAL HEAD DESCENT

Assessed by ABDOMINAL
EXAMINATION immediately
before doing a vaginal
examination

Measured by abdominal palpation using

the width of the fingers to express in
fifths the part of the fetal head palpable
above the symphysis pubis using
landmarks sinciput (S) and occiput (O)
Scrcroiooc ioints
I ac bone

lnl I i lidplait uf1_I

 DESCENT OF THE FETAL HEAD

Uses the RULE OF FIFTH to assess

Descent
• The palpable fifth of the fetal head
are felt by abdominal examination to
be above the level of symphysis pubis
• When 2/5 or less of fetal head is
felt above the level of symphysis
pubis , this means that the head is
engaged, and by vaginal
examination , the lowest part of
vertex has passed or is at the level
of the ischial spines
5/5: head completely palpated above the symphysis pubis
4/5: sinciput high; occiput easily felt
3/5: sinciput easily felt; occiput felt
2/5: sinciput: felt; occiput just felt
1/5: sinciput felt; occiput not felt
0/5: None of the head palpable; sinciput at the level of the symphysis pubis
A A Head is mobile above the
symphysis pubis = 5/5
B B Head accommodates full width of
five fingers above the symphysis
pubis
C C Head is 2/5 above the symphysis

D D Head accommodates two fingers

above the symphysis pubis
Progress of fetal descent can be estimated by measuring
the station of the fetal head relative to the ischial spine of
the maternal pelvis. Station can only be determined by
Internal examination.
FLOATING (HIGH)
▪ Unengaged presenting part
STATION -3
▪ presenting part is 3cm above the ischial spines
STATION -2
▪ presenting part is 2cm above the ischial spines
STATION -1
▪ presenting part is 1cm above the ischial spines
STATION 0/ENGAGEMENT
▪ presenting part is at the level of the ischial spines
STATION +1
▪ presenting part is 1cm below the ischial spines
STATION +2
▪ presenting part is 2cm below the ischial spines
STATION +3 OR +4
▪ the presenting part is at the perineum & can be seen if
the vulva is separated
STATION +4
▪ “crowning”
Corresponding positions of the station of the fetal head (determined by
vaginal examination) and the record of fetal descent on the partograph.

Station of fetal Corresponding

head mark on the
partograph
–4 or –3 5
–2 or –1 4
0 3
+1 2
+2 1
+3 0
 To plot the fetaI hea:d descent use the
space from 5 to Oin the same area
where you record cervica,Idilatatiion.

,
Each vertical siide of the rectangle,
.
one fifth of the head above the pelvic
·· .a. brim. For conveniience, the width of
'
the finger is used as a practiical guide.
::f; • Each hor.i:zontal si1de of the rectangle
· shows 3,0 m nute
I ' • "
❖ So plot the values of the fetal head descent (0) sign
❖ Plot at the same vertical lines as the values of the cervical
dilatation reflected with (x) sign
❖ The descent should be taken at the same time of vaginal
examination or cervical dilatation
EXAMPLE
 PART 2
PROGRESS OF LABOR
GRAPH SECTION
Divided evenly into small boxes by
gridlines vertically and horizontally

Vertical gridline = cervical dilatation in

centimeter from 4 to 10

Horizontal gridlines= Time the patient is

in active labor. Each small box is 30
minutes so each square represent 1 hour
 CERVICAL DILATATION
Assessed during every vaginal examination
made every 4 hours, unless contraindicated.

Plot cervical dilatation with (X).

Begin plotting on the partograph at 4 cm.

Represents the rates of cervical dilatation

1cm per hour.

Most important information and the surest

way to assess progress of labor
 GRAPH SECTION
TWO
ALERT LINE ACTION LINE
DIAGONAL LINES
• labelled as • starts at 4 cm of • parallel to the
Alert and Action cervical dilatation Alert line
lines. • travels diagonally • 4 hours to the
upwards to the right of the Alert
point of expected line.
full dilatation (10
cm) at the rate of
1 cm per hour.
GRAPH SECTION
• h · · Iu · o di I.· io · a j • d miss iio ·
•

should ·...· d i a t e ly plott d on t ·

al rt Un imis plot d by (X).
un · g m " ch · x v· g1 · " I
.· x - -i --: -.. ion -.lot - v ·-.Iu ,_- o - t · ·_
gr h • · d con U h i di g
a ·i . · a s o ild Iin
 If PROGRESS IS
SATISFACTORY
• plotting of cervical
dilatation REMAINS
ON OR TO THE LEFT
OF THE ALERT LINE
and should not move
to the right of the
alert line.
 _y_J
T - -
-
I I
Th cerVIcal In , doe-s L
not cross the Aler t

-
II ' I
,, _,,, :::,,.._ .,; ® 11fl ,"'
.,,-
/ --::.. .,,- .
,,,.v-
,.,6 :..----
I

I
,,,,. v-
-- I I I

- Good progre s
--- .... of descent

(a) _, _L 0
1"1-n, I
1 2 3 4 5 6 7 I
6 9 10 1 12

._,,,,.,,,,,-
110
8
I _.,,,;,
....,,. I I

c , ( rn )
B

7
0-i:;;:;.-- - IG.,;;,- . 9S?"'
,
. _..,,;;,

-- ----
P
[ l ot X) 6 .,.... ' .,,-
V
._.....,,.
ofh
T
'D es oe ll'l
d
5

1
[ lot OJ
2
1

0
Hours 1 2 ----=! s 8 ----L.. !!.
(b) TiITT I 10 1 1L 12 13 j,4 15 16 7
 If the rate of progress IS
LOWER THAN NORMAL:
• plotting of cervical dilatation
will CROSS THE “ALERT” LINE
AND THEN THE “ACTION
LINE”.
• The “action” line denotes the
critical point at which specific
management decisions
should be made to expedite
delivery.
 MOVING TO THE RIGHT OF THE ALERT LINE OR REACHES
THE ACTION LINE MEANS :

• WARNING: possible danger

• carefully reassess to determine why there is lack of
progress , and a decision must be made on further
management
• If labor occurs in birthing clinic or Rural health centers,
possible referral to hospital with facilities for cesarean
section , unless the cervix is almost fully dilated
• Continue observing labor progress for short period
• Artificial rupture of membrane(Amniotomy) may be
performed if membranes are still intact:
• Catheterization may be done
• Oxytocin augmentation
 MOVING BEYOND ACTION LINE

• the critical line at which specific

management decisions must be made at
the hospital with complete facilities
• Conduct full medical assessment
• Consider intravenous infusion / bladder
catheterization / analgesia
• Options
• - Deliver by cesarean section if there is
fetal distress or obstructed labor
• - Augment with oxytocin by intravenous
infusion if there are no contraindications
• the c _
-: _ ci a t dita jo -- e
r :__c - es or
rv cross ·· ctEo · i e i . · e ·.· s v e r y
the s lo w r e s s o la · our
.· rog
 UTERINE CONTRACTIONS
Assessed by number of contractions in a 10- minute period

Measured in seconds from the time the contraction starts

until it ends (duration)

Each square represents one contraction

Contractions are recorded every 30 minutes

On each shaded square, you
will also indicate
the duration of each
contraction by using the
symbols shown

Different shading on the

squares on the partograph
indicates the strength and
duration of contractions.
Palpate number of contraction in ten minutes and duration of
each contraction in seconds
LESS THAN 20 SECONDS:
• mild contraction (represented with dots)

BETWEEN 20 AND 40 SECONDS:

• moderate contractions (represented with diagonal lines)

MORE THAN 40 SECONDS:

• strong contractions (represented solid color)
2.
3.
..

0
 PART 3
MATERNAL CONDITION
(BOTTOM)
 PART 3 : MATERNAL CONDITION(BOTTOM)
Rows for recording
administration of :
• Oxytocin during labor and
the amount given.
• Drugs given and IV
fluids given to the
mother.
 e. C

U-.r n e ana y.sl c o e

Ur
n
Near the bottom of
the partograph:
• Record the mother’s vital
signs
• Pulse and BP with a
possible range from 60
to 180
• Temperature °C
MATERNAL PULSE RATE
BLOOD PRESSURE
TEMPERATURE
RECORD URINE OUTPUT
 PROTEIN IN THE URINE

Only a small amount or trace of protein in the

urine during pregnancy can be normal.

Larger amounts of excess protein in urine can

indicate a more serious complication such as
Pregnancy Induced Hypertension or preeclampsia
 ACETONES OR KETONES IN THE URINE
When the body burns fat instead of glucose to produce energy, it produces a by-
product called ketones.

Although ketones appear in trace amounts throughout the pregnancy, excess

ketones in urine for a considerable time could be an indication of gestational
diabetes.

During pregnancy, hormonal changes affect woman’s body’s resistance to insulin,

which plays a key role in glucose metabolism .

This prevents the body cells from utilizing the glucose in blood sugar to produce
energy. This, in turn, causes the cells to burn fats, thus producing ketones
References

Printed Textbooks:

618.20231 Si327 2018 v.1. Silbert-Flagg, J. (2018). Maternal & child health nursing: care of
the childbearing & childrearing family. Philadelphia, PA Wolters Kluwer Health.
618.20231 Si327 2018 v.2. Silbert-Flagg, J. (2018). Maternal & child health nursing: care of
the childbearing & childrearing family. Philadelphia, PA Wolters Kluwer Health.
Electronic Books :
eBooks (Ebschohost). Clair, B. (2022). Carrying on: another school of thought on
pregnancy and health. New Brunswick Rutgers University Press.
eBooks (Wiley). Yearwood, E. (2021).Child and adolescent behavioral health: a resource for
advanced practice psychiatric and primary care practitioners in Nursing. Hoboken, New
Jersey Wiley Blackwell.
eBooks (Ebschohost). Simpson K. (2021). AWHONN's Perinatal Nursing. Philadelphia, PA
Wolters Kluwer Health.
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