OBJECTIVE

STRUCTURED
CLINICAL
EXAMINATION
ON PARTOGRAPH
 INTRODUCTION
 Abnormal progress of labour is one of the most
frequent indication for primary cesarean
sections & proper management of the situation
can lower rates of operative delivery.
 Partograph is an invaluable tool to prevent
prolonged labour & to time interventions
optimally.
WHAT IS A PARTOGRAPH ?
 A Partograph is a graphical record of the observations
made on a women during labour.

 It was developed and extensively tested by the WHO.

 FRIEDMAN’S
PARTOGRAM
Friedman's partogram devised

in 1954.

 Plotting cervical dilatation

against time yielded the typical

sigmoid or 'S' shaped curve .

 Philpott and Castle
 PHILPOTT AND CASTLE in 1972 introduced the concept of "ALERT" and
"ACTION" lines.

 The alert line represented the mean rate of progress of the slowest cervical
dilatation.

 Alert line was drawn at a slope of 1 cm/hr .

 Action line drawn 4 hours to the right of the alert line.

WHY ONE SHOULD USE A
PARTOGRAPH?

 The Partograph is designed for use in all maternity settings but has

a different level of function at different levels of health care.

 In Periphery, the Partograph serves as early warning (ALERT LINE

FUNCTION )

 In hospital settings, moving to the right of alert line serves as a

warning for extra vigilance , but the action line is the critical point at

which specific management decisions must be made.

 other observations of essential features of the progress of labour

are also recorded on the Partograph.

 LETS SEE THE
EVOLUTION OF
PARTOGRAPH
 Since 1990 ,WHO has published 3 different types of the Partograph.

 1.COMPOSITE PARTOGRAPH-
 The first Partograph is Composite Partograph includes a latent phase of 8
hours and an active phase starting at 3 cm cervical dilatation.
 It has an alert line with a slope of 1 cm per hour which commences at 3 cm
dilatation and an action line is 4 hours to the right of and parallel to the
alert line.
 It also provides space for recording
 Descent of the fetal head,
 Indicators of maternal and fetal well-being and
 Medication administered (WHO, 1994)
2. MODIFIED PARTOGRAPH
 WHO modified the Partograph for
use in hospitals in 2000 (WHO,
2000).
 The latent phase was excluded in
this Partograph.
 The active phase commences at 4
cm dilatation.
 The reason for excluding the latent
phase was that interventions are
more likely if latent phase is
included and because staff reported
difficulties in transferring from
latent to active phase.
3.SIMPLIFIED PARTOGRAPH-
 WHO further modified the Partograph
for the third time, this time for use by
skilled attendants in health centres.
 This simplified Partograph is colour
coded.
 The area in between the alert and
action line is coloured amber,
indicating the need for greater
vigilance.
 Cervical dilatation not descent of the
head is recorded on the Partograph
which is a part of labour record. Other
indications of maternal and fetal
in the
wellbeing are recorded
labour record (WHO, 2006).
 COMPONENTS OF A
PARTOGRAPH
 Biodata:
 Part 1 : Fetal condition (at top )
 Part 2 : Progress of Labour ( at middle )

 Part 3 : Maternal condition ( at bottom)

 Outcome : ………………

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HOW TO PLOT
Identification data
 Name
 Age,
 Parity,
 Date and time of admission
 Registration number;
 Time of rupture of membranes.
 Plotting A Partograph
Fetal Condition
 Count & record FHR
every 30 minutes.
 Count for 1 full minute,
immediately following a
uterine contraction
 Fetal distress:

 FHR <120 beats/minute

or >160 beats/minute

Arrange for referral 14

 Plotting A Partograph
Record status of membranes and amniotic fluid color
every 30 minutes in Partograph as follows:
 Membranes intact (mark ‘I’)
 Blood stained (mark ‘B’)
 Clear liquor (mark ‘C’)
 Meconium stained liquor (mark ‘M’)

Use sterile perineal pad to look for colour of liquor

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and status of membrane
Membranes and liquor
State of Liquor Record

Membranes intact I

Clear C

Meconium M

Blood Stained B

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 PLOTTING A PARTOGRAPH

X
 In the centre of Partograph is a
Graph. X

DR SNG
 Along the left side(Y-Axis) are
numbers 0 -10 against squares. Each
X
square represents 1cm dilatation.

 Along the bottom(X Axis) of the

graph are numbers 0 onwards. 1 2 3 4 5 6 7 8

Each square represents 1hour 11 12 13 14 15 16 17 18

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 PLOTTING A PARTOGRAPH
Labour
 Begin plotting in active labor. X

DR SNG
 Cervical dilatation ≥ 4 cm and > 1
X
contractions / 10 minutes

 Plot the initial finding at Alert line X

by making with a (×). Note the
time.

 Repeat P/V after 4 hours and plot 1 2 3 4 5 6 7 8

the cervical dilatation
11 12 13 14 15 16 17 18
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 DESCENT OF FETAL HEAD
 It is measured in terms of fifths above the pelvic brim

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PLOTTING A PARTOGRAPH

Chart the contractions every 30 minutes.

 Number of contractions in 10 mins

 Duration in seconds.

 Less than 20 seconds

 Between 20 and 40 seconds

 More than 40 seconds

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 RECORDING UTERINE CONTRACTIONS
On the Partograph below the time line, there are 5 blank
squares going across the length of the graph. Each square
represents 1 contraction

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 MATERNAL CONDITION
Recorded at the foot of the Partograph

Oxytocin:
Drugs:

DR SNG
Pulse: every 30 minutes
BP: every 4 hrs or more frequently
Temp: every 4 hrs or more frequently
Urine: Protein

Acetone

Volume

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MANAGEMENT OF LABOUR USING
PARTOGRAPH

 Progress in active phase remains at or left to alert line.

 No Oxytocin in latent Phase or in normal progress of labour.

 ARM in active labour only.

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BETWEEN ALERT & ACTION LINES
 Continue routine observations
 ARM may be performed if membranes are still intact
 Observe labor progress for short period before
transfer
 In health center , the women must be transferred to a
hospital with facilities for cesarean section .

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CROSSING ACTION LINE

 Crossing of the Action line (the plotting moves to

the right of the Action line) : indicates the need for
intervention.

 By the time the action line is crossed the woman

should ideally have reached the FRU for the
appropriate intervention to take place.
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E-PARTOGRAPH
 Jhpiego and the Johns Hopkins Center for Bioengineering Innovation and
Design - a handheld device and software platform based on the current
partogram recommended by the WHO.
 The device expands the benefits of the paper-based version through the
following improvements: 
 Features efficient data entry, automatic plotting of observations
 Provides instant graphing of data
 Reminds providers when to measure and record critical observations 
 Stores multiple patient data in one device 
 Provides indicators when complications arise
 Limits retroactive data entry after delivery (a current practice that reduces
the current paper partogram into a mere recording tool)
 Transmits data to off-site experts who can provide guidance and support
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Components of Partogram

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PARTOGRAPHCASE STUDY
Radha (wife of Gangaram), 26 years of age, third gravida, was admitted at 5:00 am on 11 June 2009 with
the complaint of labour pains since 2:00 am.
Her membranes had ruptured at 4:00 am. She has two children of the ages of 5 and 2 years.
On admission, her cervix was 2 cm dilated
Plot the following findings on the partograph
:At 09:00 am
• The cervix is dilated 5 cm.. She had 3 contractions in 10 minutes,
• The FHR is 120 beats per minute each lasting 20-40 seconds
.• The membranes have ruptured and the amniotic fluid is clear.
• Her BP is 120/70 mmHg.
• Her temperature is 36.8"C.
• Her pulse is 80 per minute.
9:30 am: FHR 120, contractions 3/10 each 30 seconds, pulse 80/minute, amniotic fluid clear
10:00 am: FHR 136, contractions 3/10 each 35 seconds, pulse 80/minute, amniotic fluid clear
10:30 am: FHR 140, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:00 am: FHR 130, contractions 3/10 each 40 seconds, pulse 88/minute, amniotic fluid clear
11:30 am: FHR 136, contractions 4/10 each 45 seconds, pulse 84/minute, amniotic fluid clear
12:00 noon: FHR 140, contractions 4/10 each 45 seconds, pulse 88/min
12:30 pm: FHR 130, contractions 4/10 each 50 seconds, pulse 88/minute, amniotic fluid clear.
At 1:00 pm: FHR 140, contractions 4/10 each 55 seconds, pulse 90/minute, temperature 37°C, BP100/70
mmHg, amniotic fluid clear
• Cervix fully dilated
• Amniotic fluid clear
• BP 100/70 mmHg
At 1:20 pm: Spontaneous birth of a live female infant weighing 2.85 kg.
DYSFUNCTIONAL LABOUR
 Mrs XYZ, G2P1L1 at 39 weeks came to GMCH,
Aurangabad at 10 am with complaints of premature
rupture of membranes since 4 hours. The mother was
observed for another 2 hours.
 At 12 pm, on per vaginal examination, she was 4 cm
dilated and the partograph plotted.
Patient is augmented with inj
oxytocin @8 drops/min,
followed by 16 drops /min ,
followed by 32 drops /min

After augmentation, the cervical

dilatation progressed to 6 cm ,
FHS drops of 90/min were
documented and decision of
LSCS was taken

This patient is observed for 4

hours and it’s found that the rate
of cervical dilatation is <1cm/ hr.

Contraction @2/10’/20”
PROTRACTED ACTIVE PHASE DILATATION
 XYZ, Primigravida at 38 weeks came to GMCH
Aurangabad, in active labor. On admission, she was 4cm
dilated .
 Partograph was plotted
 She was assessed after 3
hours of admission. She
was still 4 cm dilated with
uterine contractions
@3/10’/20”.

3 P s assessed
Inad

Incordinate uterine
contractions

Inj oxytocin was titrated

from 8 drops/ min after
which there was progress in
cervical dilatation and
patient delivered vaginally
SECONDARY ARREST OF DILATATION
 Mrs XYZ , primigravida at term came to GMCH
Aurangabad with complaints of pain in abdomen and
leaking per vaginum since 6 hours. On examination she
was 4 cm dilated .
 Partograph was plotted.
 The 3 P s , power, passage
and passenger were
evaluated 4 hours after
admission .

Inspite of uterine
contractions @
Cervical dilatation 4/10’/40”, the
progressed from 4 cm to dilatation did not
6 cm in 4 hours with the progress further.
uterine contractions @
3/10’/30”.
Since drops in
fetal heart were
detected,
patient was
taken for LSCS
SECONDARY ARREST OF DILATATION
WHO COMPOSITE
WHO Modified Partograph
PARTOGRAPH
DESCENT OF FETAL HEAD
HOW TO PLOT ?

1 2 3 4 5 6 7 8 9 10 11 12

11 12 13 14 15 16 17 18 19 20 21 22
ABNORMAL LABOUR PATTERN
DISORDER NULL MULTI CAUSES TREATMENT
IPAR PARA preferred exceptiona
A l

PROTRACT <1 <2cm/ •CPD •Expectant & For CPD,

ED cm/h hr •Malposition support caesarean
DESCENT r •Hypotonic •Amniotomy delivery
uterine •Oxytocin
contractions augmentation
•Epidural
analgesia

ARREST OF >1 hr >1 hr •CPD •If no CPD, For CPD,

DESCENT •Malposition amniotomy and caesarean
FAILURE No descent in •Inco ordinate Oxytocin delivery
OF deceleration uterine augmentation
DESCENT phase or in contraction
second stage
 ABNORMAL LABOUR PATTERN

DILATATION DESCENT

PROTRACTED FAILURE
ARREST

Always assess 3 Ps
 POWER
 PASSAGE
 PASSENGER
NORMAL DESCENT
PROTRACTED DESCENT
ARREST OF DESCENT
SUMMARY
•A Partograph is a graphical record of the observations made on
women during labour.
• The Partograph was designed by Friedman in 1954 and further
improved by Philpot and Castle who introduced action and alert line.
• Since 1990 ,WHO has published 3 different types of the Partograph;
these are
1) WHO Composite Partograph
2) WHO Modified Partograph
3) WHO Simplified Partograph
• Component of Simplified Partograph are:

1)Identification: Name ,Age, Parity, Date and time of admission,

Registration number, Time of rupture of membranes
2) Foetal condition: FHS, status of membrane, liquor condition
3) Labour progress: Cervical dilatation and Contractions
4) Maternal condition: Pulse, BP, Temperature
• Advantage of Partograph:
1) Increases the quality of all observations on mother and fetus in labour.
2) A single sheet of paper can provide details of necessary information at a glance.
3) Make observation and recording of feto-maternal condition more objectively.
4) Serve as “Early warning system” such as abnormal progress of labour, prolong
labour.
5) It assists in early decision, augmentation , termination of labour.
6) Introduction of Partograph in the management of labour has reduced the incidence
of prolong labour and cesarean section rate.
WHO recommendations (2018)

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