Monitoring of Normal Labour

(Partograph)
Associate Professor Dr. Anisah Jalaluddin
 Diagnosis of labour

Regular painful contractions resulting in progressive change

of the cervix

+/- show
+/- rupture of membranes
 Partograph
• A partograph is a
graphical record of the
observations made of a
women in labour
• It was developed and
extensively tested by
the world health
organization WHO
WHO partograph
 Objectives
• Early detection of abnormal progress of a labour
• Prevention of prolonged labour
• Recognize cephalopelvic disproportion long before obstructed
labour
• Assist in early decision on transfer, augmentation, or
termination of labour
• Increase the quality and regularity of all observations of
mother and fetus
• Early recognition of maternal or fetal problems
 Components – 4

FETAL PROGRESS OF MATERNAL

ID
CONDITION LABOUR CONDITIONS
 Partograph
Patient Information

Fetal condition

Progress of Labour

Medications

Maternal condition

7
PART 1
Patient information ID
FETAL CONDITION
PART 2
 Part 2 : Fetal condition
This part of the graph is used to monitor & assess
fetal condition
1 - Fetal heart rate
2 - Membranes and liquor
3 - Moulding the fetal skull bones
Caput
 Fetal heart rate
Basaline fetal heart rate.
160 beats/min - tachycardia
Ø 110 beats/min = bradycardia
Ø 100 beats/min = severe bradycardia

Decelerations? yes/no
If yes - Relation to contractions?
– Early
– Variable
– Late
 Membranes and liquor
• I - intact membranes
• C- ruptured membranes + clear liquor
• M- ruptured membranes + meconium- stained liquor
• B - ruptured membranes + blood – stained liquor
• A- ruptured membranes + absent liquor
 Meconium

Grade 1 Grade 2 Grade 3

Light Both liquor & Meconium
green or meconium are dominates over
yellow. drained in liquor passed as
equal amounts semisolids material 14

or black paste
Moulding the fetal skull bones

Moulding is an important
indication of how adequately
the pelvis can accommodate
the fetal head
Increasing moulding with the
head high in the pelvis is an
ominous sign of cephalopelvic
disproportion
Moulding the fetal skull bones
Degree of moulding

separated bones sutures 0

felt easily

bones just touching each +

other

overlapping bones ++
(reducible)

severely overlapping +++

bones ( non – reducible )
PROGRESS OF LABOUR
PART THREE
 Progress of labour
Cervical dilatation
• Descent of the fetal head
• Fetal position
• Uterine contractions
• this section of the
paragraph has as its
central feature a graph of
cervical dilation against
time
• it is divided into a latent
phase and an active
phase
 Latent phase
• starts from onset of labour until the cervix reaches 4 cm
dilatation
• once 4 cm dilatation is reached , labour enters the active
phase
• lasts 8 hours or less
• each lasting > 20 seconds
• at least 2/10 min contractions
 Active phase

• Contractions at least 3 / 10 min

• each lasting > 40 sceonds
• The cervix should dilate at a rate of 1 cm / hour or faster
 Alert line ( health facility line )

• The alert line drawn from 4 cm dilatation

represents the rate of dilatation of 1 cm / hour
• Moving to the right or the alert line means
referral to hospital for extra vigilance
 Action line

• The action line is drawn 4 hour to the right of

the alert line and parallel to it
• This is the critical line at which specific
management decisions must be made at the
hospital
 PROGRESS OF LABOUR
6 hrs (12 squares)

6 cm

4 hours

½ hr 1 hr

ALERT LINE – starts at 4 cm of cervical dilatation to the point of

expected full dilatation (10 cm) at the rate of 1 cm per hour

ACTION LINE – parallel and four hours to the right of alert line

23
 Cervical diltation
• It is the most important information and the surest way to
assess progress of labor
• When progress of labor is normal and satisfactory, plotting of
cervical dilatation remains on the alert line or to left of it
• If a woman arrives in the active phase of labor , recording of
cervical dilatation starts on the alert line
• When the active phase of labor begins, all recordings are
transferred and start by plotting cervical dilatation on the
alert line
 Descent of the fetal head
• It should be assessed by abdominal
examination
• The rule of fifth means 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
Assessing descent of the fetal head by vaginal
examination;
0 station is at the level of the ischial spine (Sp).
 PROGRESS OF LABOUR
CERVICAL DILATATION
Y axis – recorded as X

Descent of the fetal head

Y axis – 0 to 5

Recorded as a circle O
at every abdominal
examination
INITIAL PLOTTING – on the VERTICAL LINE at which cervical dilatation
is recorded (according to the no of fifths palpated)
27
 Fetal position

Occiput transverse positions

Occiput anterior positions

 Uterine contraction
Duration Symbols
<20 sec

Uterine contractions 20-40 sec

>40 sec

3 in 10 minutes – 35 seconds 4 in 10 minutes – 50 seconds

RECORD
number of contractions in 10 min and their duration in seconds.

29
MATERNAL CONDITION

PART 4
 Part 4: maternal condition
Assess maternal condition
regularly by monitoring
• Drugs, IV fluids, &
oxytocin.
• Pulse & BP
• Temperature
• Urine volume protein &
acetone
Management of labour using the
partograph
Latent phase is less than 8 hours
progress in active phase remains
on or left of the alert line
• Do not augment with oxytocin if latent
and active phases go normally
• Do not intervene unless complications
develop
Artificial rupture of membranes
• No ARM in latent phase
• ARM at any time in active phase
 First stage of Labour

Cervical Contractions
dilatation in 10 minutes
First stage
Duration
cm Frequency Duration
Rate

Latent phase 0–3 not > 8 hrs 1

>20
seconds
Active phase 4 – 10 1cm / hr >2
ABNORMAL PROGRESS OF LABOR
• One of the main functions of the partograph is
to detect early deviation from normal
progress of labor
 Components of normal labour
• Patient
– pain , bladder empty , dehydration
, exhaustion
• Powers
– Uterine contractions
– Maternal effort
• Passages
– Maternal pelvis ( Inlet - Outlet )
– Maternal soft tissue
• Passenger
– Fetal ( size - presentation - position
– Moulding)
– Cord
– placenta
– membranes
 Moving to the right of alert line

• This means warning

• Transfer the woman from health center to
hospital
• reaching the action line
• This means possible danger
• Decision needed on future management
(usually by obesteritian or resident )
Prolonged latent phase
If a woman is admitted in labor in the latent phase ( less than 4 cm dilatation ) and remains in the
latent phase for next 8 hours
Progress is abnormal and she must be transferred to a hospital for a decision about further action
This is why there is a heavy line drawn on the partograph at the end of 8 hours of the latent phase
Prolonged
Active phase
Secondary arrest of
cervical diltation

• Abnormal progress of
labor may occur in cases
with normal progress of
cervical dilatation then
followed by secondary
arrest of dilatation
 Secondary arrest of head descant

• Abnormal progress of labor may occur with normal progress of

descent of the fetal head then followed by secondary arrest of
desscent of fetal head
 Precipitate Labour

- Maximum slope of dilatation of 5 cm/hr or

more
USING THE PARTOGRAPH POINTS
TO REMEMBER
• It is important to realize that the partograph is a tool for
managing labor progress only
• The partograph does not help to identify other risk factors
that may have been present before labor started
• Only start a partograph when you have checked that there are
no complications of pregnancy that require immediate action
• A partograph chart must only be started when a woman is in
labor,-- be sure that she is contracting enough to start a
partograph
• If progress of labor is satisfactory , the plotting of cervical
diltation will remain or to the left of the alert line
• when labor progress well, the dilatation should not move to
the right of the alert line
• the latent phase. 0 – 3 cm dilatation , is accompanied by
gradual shortening of cervix. normally, the latent phase
should not last more than 8 hours
• the active phase, 4 – 10 cm dilatation, should progress at
rate of at least 1 cm/hour
• when admission takes place in the active phase, the
admission dilatation, is immediately plotted on the alert line
• when labor goes from latent to active phase , plotting of the
dilatation is immediately transferred from the latent phase
area to the alert line
• dilatation of the cervix is plotted (recorded with an X, descent of
the fetal head is plotted with an O, and uterine contractions are
plotted with differential shading)
• descent of the head should always be assessed by abdominal
examination ( by the rule of fifths felt above the pelvic brim )
immediately before doing a vaginal examination
• assessing descent of the head assists in detecting progress of labor
• increased moulding with a high head is a sign of cephalopelvic
disproportion
• vaginal examination should be performed infrequently as this is
compatible with safe practice (once every 4 hours is recommended)
• when the woman arrives in the latent phase, time of admission is 0
time
• A woman whose cervical dilatation moves to the right of the
alert line must be transferred and managed in an institution
with adequate facilities for obstetric intervention , unless
delivery is near

• Partograph reaches the action line , she must be carefully

reassessed to determine why there is lack of progress , and a
decision must be made on further management (usually by an
obstetrician)
IMPORTANT COSIDERATIONS
 OXYTOCIN
• Titrates against uterine
contractions and increased every
half- hour until contractions are 3
or 4 in10 minutes, each lasting 40
– 50 seconds
• Maintained at the rate throughout
the second stage of labor
• Stop infusion if there is evidence
of uterine hyperactivity and / or
fetal distress
• Used with caution in multiparous
women
• Augment with oxytocin only after
artificial rupture of membranes
and provided that the liquor is
clear
THANK YOU