By sumanOn

A graphical representation of the foetal and maternal conditions during labour, as well as the progress of labour, is called a partograph. It is the most effective method for determining if labour is moving properly or abnormally, as well as for alerting the mother if her vital signs are out of the ordinary range or if there are indications of foetal distress.

The partograph, sometimes known as a partogram, has become the “gold standard” labour monitoring instrument around the world. The World Health Organisation (WHO) recommends it for use during active labour. The partograph’s function is to monitor labour progress and detect and assist in cases of abnormal labour.

The WHO has advised using the partograph, a low-tech paper form that has been recognised as an excellent tool for detecting maternal and foetal problems during childbirth. Despite decades of training and effort, implementation rates and capacity to appropriately use the partograph remain low in resource-constrained environments. Nonetheless, proper use of the partograph, particularly with modern technology, can save mother and foetal lives by ensuring that labour is closely monitored and that life-threatening problems like obstructed labour are diagnosed and treated.

To overcome the issues of utilizing partograph among health workers, healthcare institutions must create a climate that encourages proper use. It is important to keep medical staff informed by asking them about challenges they have encountered at their health centre and by offering training. Then and only then can this amazing tool’s true potential be fully realised.

When a woman is in labour, all observations are documented using a partogram. The following points are noted in it.

1. The head descent, uterine contractions, and cervical dilatation all indicate the status of labour.
2. The foetal heart rate, amniotic fluid colour, and foetal skull moulding all indicate the health of the foetus.

3. Pulse, blood pressure, temperature, urine production, and urine’s protein and acetone content are used to evaluate the health of mothers.
4. Drugs, IV fluids, and oxytocin are placed in a separate area.

Progress of Labour

Plotting cervical dilatation on a graph is the partogram’s main component. Squares ranging from 0 to 10 along the left side indicate dilation of 1 cm. Each of the numbers 0 through 24 down the graph’s bottom represents one hour.
There are two phases to the initial stage of labour: latent and active. The latent phase lasts for up to eight hours and spans from 0 to 4 cm. Between 4 and 10 cm is the active phase (full cervical dilatation). Plotting of the cervix dilation is done with “x.”
The cervical dilatation is plotted on the alert line when a woman is admitted while in the active phase.The charting of cervical dilatation will stay on the left of the alert line if labour progresses satisfactorily. Plotting a dilatation of 0 to 3 cm in the latent phase is recommended for women who are admitted during this period. However, as indicated by the broken line, the recording needs to be moved to the alert line when the woman enters her active period. The charting of cervical dilatation will stay on the left of the alert line if labour progresses satisfactorily.

Normal Progress of Labour

Plotting a dilatation of 0 to 3 cm in the latent phase is recommended for women who are admitted during this period. However, as indicated by the broken line, the recording needs to be moved to the alert line when the woman enters her active period.

Transferring Cervical dilatation to the alert line in the active phase of labor pain

Foetal Head Descent Before performing a vaginal examination, the descent of the head should always be evaluated by an abdominal examination since the large caput may provide an inaccurate assessment of the station. Abdominal palpation level of the foetal head is represented in terms of fifths above the brims.
The graph’s left side features the word “descent,” surrounded by numbers ranging from 5 to 0. “O” is used to plot descent on a cervicograph.

Plotting decent of the fetal Head

Contractions in the Uterus The scale is numbered from 1 to 5 and is located beneath the cervical dilation. It is used to record the number of uterine contractions per 10 minutes. One contraction is shown by each square. Thus, two squares are darkened if two contractions are felt in ten minutes. The following symbols show the duration and intensity of contraction:

Intensity and duration of the Uterine Contraction

Fetal Condition

The foetal heart rate record is located just below the mother’s identification details. Foetal heart rate ranges between 100 and 180 beats per minute.

Amniotic Fluid

Below the foetal heart rate, there are two rows, the first for amniotic fluid (Liquor). When the membranes rupture, the colour of the amniotic fluid is observed.

  1. If the membranes are intact, need to write ‘I’
  2. If the amniotic fluid (liquor) is clear, write ‘C’
  3. If the amniotic fluid (liquor) is meconium-stained, write ‘M’
  4. If the amniotic fluid (liquor) is Blood stained, write ‘B’
  5. If the amniotic fluid (liquor) is absent, write ‘A’

Note: In some cases you may see the presence of meconium and blood in that scenario you need to write M and B both.

Moulding

The row beneath the liquor is designated for moulding. An increasing moulding with a high head in the pelvis is an unfavourable symptom. It is recorded as follows.

  • 0 Bones have been separated, and the sutures are easily felt.
  • +Bones are simply touching each other
  • ++Bones are overlapping
  • +++Bones are overlapping heavily

Maternal Condition

All maternal condition recordings are entered at the foot of the partograph, below the uterine contraction record. Maternal vital signs include temperature, pulse, blood pressure, urine output, and protein and acetone levels in urine.

The importance of alert and action lines During the active period of normal labour, cervical dilatation will be plotted to the left of or on the alert line. If it shifts to the right of the alert line, labour could be prolonged. Transfer the patient if an emergency intervention facility is not available. Transfer offers enough time for assessment or intervention before she reaches the action line. The action line is 4 h to the right of the alert line.Determine the cause of the slow progress and take appropriate measures. Action should be made in a location with access to obstetric emergency care facilities.

Exercise:

E.1. Geeta, Ganesh’s wife, was hospitalised at 10:00 a.m. on July 15, 2023, with complains of labour pains since eight in the morning. This is her first child.

Now Plot the following findings on the partograph:

Exercise: At 11:00am: The cervix is dilated 4 cm. She had 2 contractions in 10 minutes, each lasting less than 20 seconds. The FHR is 140 per minute. The membranes are still intact. Blood pressure is 100/70 mmHg.  Body temperature is 36.5°C. Her pulse rate is 90 per minute.

  • 11:30 am: FHR 130, contractions 2/10 each 20 seconds, pulse 80/minute
  • 12:00 am: FHR 146, contractions 2/10 each 20 seconds, pulse 90/minute
  • 12:30 am: FHR 136, contractions 2/10 each 30 seconds, pulse 100/minute
  • 1:00noon: FHR 150, contractions 3/10 each 34 seconds, pulse 90/minute, membranes ruptured and amniotic fluid clear
  • 1:30 pm: FHR 146, contractions 3/10 each 35 seconds, pulse 84/minute, amniotic fluid clear
  • 2:00 pm: FHR 155, contractions 4/10 each 45 seconds, pulse 90/minute, amniotic fluid meconium-stained
  • 2:30 pm: FHR 160, contractions 4/10 each 45 seconds, pulse 100/minute, amniotic fluid meconium-stained
  • At 3:00 pm: Cervix dilated 5 cm. Amniotic fluid meconium-stained. Contractions 4/10 each 45 seconds. FHR 166/minute. Pulse100/minute. Temperature 37.6°C. BP 136/85 mmHg.

E.2 STEP 1. Mrs. C was admitted at 10.00 on 19 September 2013. Membranes ruptured spontaneously at 04.00. She is a gravida 4, para 3+0. Her hospital number is 6639.

Record the information above on the partogram, together with the following details:

  • Fetal head 3/5 palpable above the symphysis pubis
  • Cervix 4 cm dilated
  • 3 contractions in 10 minutes, each lasting 30 seconds
  • FHR 140
  • Amniotic fluid clear
  • Sutures apposed (Molding +)
  • Blood pressure 120/70 mmHg
  • Temperature 36.8°C
  • Pulse 80/minute

STEP 2. Plot the following information in the partogram:

  • 10.30     FHR 130, Contractions 3/10 each 45 seconds, Pulse 80/minute
  • 11.00     FHR 136, Contractions 3/10 each 45 seconds, Pulse 90/minute
  • 11.30     FHR 140, Contractions 3/10 each 45 seconds, Pulse 88/minute
  • 12.00     FHR 140, Contractions 3/10 each 45 seconds, Pulse 90/minute, Temperature 37°C, Head 3/5 palpable
  • 12.30     FHR 130, Contractions 3/10 each 45 seconds, Pulse 90/minute
  • 13.00     FHR 130, Contractions 3/10 each 50 seconds, Pulse 88/minute
  • 13.30     FHR 120, Contractions 3/10 each 50 seconds, Pulse 88/minute
  • 14.00     FHR 130, Contractions 3/10 each 50 seconds, Pulse 90/minute, Temperature 37°C, Blood Pressure 100/70 mmHg. Fetal head 3/5 palpable above the symphysis pubis. Cervix 6 cm dilated, amniotic fluid clear. Sutures overlapped but reducible (Molding ++).

STEP 3. Plot the following information in the partogram:

  • 14.30     FHR 120, Contractions 3/10 each 45 seconds, Pulse 90/minute, Clear fluid
  • 15.00     FHR 120, Contractions 3/10 each 45 seconds, Pulse 88/minute, Blood-stained fluid
  • 15.30     FHR 100, Contractions 3/10 each 45 seconds, Pulse 100/minute
  • 16.00     FHR 90, Contractions 3/10 each 50 seconds, Pulse 100/minute, Temperature 37°C
  • 16.30     FHR 96, Contractions 4/10 each 50 seconds, Pulse 110/minute. Fetal head 3/5 palpable above the symphysis pubis.  Cervix 6 cm dilated.  Amniotic fluid meconium stained. Sutures overlapped and not reducible.  Urine output 100 mL; protein negative, acetone 1+.

STEP 4. Record the following information on the partogram:

  • Cesarean section at 17.30, live female infant with poor respiratory effort and weighing 4,850 g.

Answer the following questions:

Q: What is the final diagnosis?

Q: What action was indicated at 14.00, and why?

Q: What action was indicated at 15.00, and why?

Q: At 17.00, a decision was taken to do a cesarean section, and this was rapidly done. Was this a correct action?

Q: What problems may be expected in the newborn?

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