1. PLOTTING A PARTOGRAPH
Dr Sunita Singal

2. AimsAims
 To understand the use of theTo understand the use of the
partographpartograph
 Practice using the partographPractice using the partograph
 To recognise slow progress in labourTo recognise slow progress in labour
and manage it appropriatelyand manage it appropriately

3. Partograph:Partograph:
 a graphical record of progress in laboura graphical record of progress in labour
 Should be used for all deliveriesShould be used for all deliveries
 Start using once the woman is in labourStart using once the woman is in labour

4. LabourLabour
 A correct diagnosis of labour has to beA correct diagnosis of labour has to be
made before opening the partographmade before opening the partograph
 2-3 uterine contractions in 10mins2-3 uterine contractions in 10mins
 Progressive shortening and thinning of theProgressive shortening and thinning of the
cervix during labour andcervix during labour and
 Cervical dilatationCervical dilatation 4cm4cm or more dilated:or more dilated:
openopen partographpartograph

5. Monitoring of first stage of labourMonitoring of first stage of labour
In Latent Phase
After 8 hours
Contractions stronger, more
frequent, no change in
dilatation or effacement
ROM +/-
REFER to FRU
Prolonged latent phase
No increase in intensity /
frequency / duration of
contractions, membranes
not ruptured and no
progress in cervical
dilatation
Ask woman to relax

6. Beware of false labourBeware of false labour
 Regular pains, but no progressive cervical dilatationRegular pains, but no progressive cervical dilatation
 Consider causes ? UTI, ? BV, ? infectionConsider causes ? UTI, ? BV, ? infection
 ? Prolonged latent phase? Prolonged latent phase
 Contractions persist mild-moderateContractions persist mild-moderate
 At termAt term
 CX less than 3cmCX less than 3cm
 Membranes intactMembranes intact
 BEWARE strong contractions without progress, checkBEWARE strong contractions without progress, check
lie, presentation- act fast- REFERlie, presentation- act fast- REFER

7. True labour pains False labour pains
Regular and predictable Irregular
Felt first in lower back & sweeps
towards lower abdomen
Remains confined to
lower abdomen
Not relieved by rest Often relieved by rest
Increase in duration , intensity
and frequency with time
Does not increase in
duration, intensity or
frequency
“Show” present “Show” absent
Accompanied by cervical
changes
Not accompanied by
cervical changes

8. ModifiedModified
WHOWHO
PartographPartograph

10. Filling a Partograph
• Identification data
– Name
– Age,
– Parity,
– Date and time of
admission
– Registration number;
– Time of rupture of
membranes.

11. Fetal monitoringFetal monitoring

12. Fetal monitoring

13. LIQOUR
I Membranes intact
C Clear liqour
M Meconium stained liqour
B Blood stained liqour
MOULDING
+ sutures apposed
++ sutured overlapped, reducible
+++ sutures overlapped, irreducible

14. Plotting a partographPlotting a partograph
Interventions
– Mention dose, route and
time of administration of
any drug
– Mention the food items and
liquids consumed

15. Maternal vital signs

16. Progress in labourProgress in labour
 Regular contractionsRegular contractions
< 20 sec,< 20 sec, 20-40 sec,20-40 sec, > 40 sec> 40 sec
 Dilatation of cervix –at least 1cm per hourDilatation of cervix –at least 1cm per hour
(follows alert line)(follows alert line)
-- chart aschart as XX
 Descent of presenting part in fifthsDescent of presenting part in fifths
paplablepaplable
-- chart aschart as OO

17. Plotting a partographPlotting a partograph
Labor
• Begin plotting in active labor
• Cervical dilatation > 4 cms
• Repeat P/V after 4 hours and plot the cervical dilatation

18. Progress of Labor

19. ALERT and ACTION linesALERT and ACTION lines
• Alert line: A line starts at 4 cm of cervical dilatation to
the point of expected full dilatation at the rate of 1 cm per
hour.
• Moving to the right or the alert line may require referral to
hospital for extra vigilance
• Action line: Parallel and 4 hours to the right of the alert
line. A lag time of 4 hours between a slowing of labour
and the need for intervention.
• When Action line is reached this is the critical line at
which specific management decisions must be made

20. Note that the first plotNote that the first plot
on the partographon the partograph
starts on the Alert Linestarts on the Alert Line

21. x
x
o o
SlowSlow
progressprogress
in labourin labour

22. Between alert and action linesBetween alert and action lines
• At lower level facility, the women must be transferred toAt lower level facility, the women must be transferred to
a higher level facility which can do a cesarean section,a higher level facility which can do a cesarean section,
unless the cervix is almost fully dilatedunless the cervix is almost fully dilated
• Continue routine observations but prepare for transfer ifContinue routine observations but prepare for transfer if
neededneeded
• ARM may be performed if membranes are still intactARM may be performed if membranes are still intact

23. Crossing the 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

24. At or beyond action line:InterventionAt or beyond action line:Intervention
• Repeat full medical assessmentRepeat full medical assessment
• Consider intravenous infusion / bladder catheterization /Consider intravenous infusion / bladder catheterization /
analgesiaanalgesia
• OptionsOptions
 Augment with oxytocin by intravenous infusion only if there areAugment with oxytocin by intravenous infusion only if there are
no contraindicationsno contraindications
 Refer to a higher level facilityRefer to a higher level facility
 Deliver by cesarean section if there is fetal distress orDeliver by cesarean section if there is fetal distress or
diagnosis is obstructed labourdiagnosis is obstructed labour

25. Slow progress in labour ?Slow progress in labour ?
PowersPowers
 Inadequate contractions (dysfunctional labour)Inadequate contractions (dysfunctional labour)
PassagePassage
 Pelvis too small for baby (cephalopelvic disproportionPelvis too small for baby (cephalopelvic disproportion
– CPD)– CPD)
PassengerPassenger
 Abnormal presentation or position ( e.g. transverse)Abnormal presentation or position ( e.g. transverse)
 Fetal abnormality (e.g. hydrocephalus)Fetal abnormality (e.g. hydrocephalus)

26. PowersPowers
 Slow progress often due to inadequate uterineSlow progress often due to inadequate uterine
contractionscontractions
 Restore normal progress by:Restore normal progress by:
- rupturing membranesrupturing membranes
- giving syntocinon by IV infusion where allowedgiving syntocinon by IV infusion where allowed
- consider referral to FRUconsider referral to FRU
 Reassess in 2 hoursReassess in 2 hours
 If no further progress REFER for CSIf no further progress REFER for CS

27.  Cephalopelvic disproportion (CPD)Cephalopelvic disproportion (CPD)
 Malpresentation or MalpositionMalpresentation or Malposition
 Fetal abnormalityFetal abnormality
Passage or Passenger:Passage or Passenger:

28. Remember!Remember!
 Slow progress may be due to any of theSlow progress may be due to any of the 3Ps3Ps
 Augmentation with syntocinon may beAugmentation with syntocinon may be
dangerous and cause rupture of uterusdangerous and cause rupture of uterus

29. Slow progress in second stage:Slow progress in second stage:
 Delay in descent of presenting partDelay in descent of presenting part
 Delay in expulsionDelay in expulsion

30. Slow progress in secondSlow progress in second
stage: Managementstage: Management
 Review maternal positionReview maternal position
 Consider augmentationConsider augmentation
 If fetal head >2/5 palpable deliver by CSIf fetal head >2/5 palpable deliver by CS
(Refer)(Refer)
 If fetal head < 1/5 palpable assist deliveryIf fetal head < 1/5 palpable assist delivery
by vacuum extraction (if avaliable)by vacuum extraction (if avaliable)

31. IfIf slowslow progress becomesprogress becomes nono
progress and no action isprogress and no action is
taken labour becomestaken labour becomes
obstructedobstructed.

32. RECAPRECAP
When to start the partographWhen to start the partograph
Correct diagnosis of labourCorrect diagnosis of labour
 Diagnosis and management of slowDiagnosis and management of slow
progress in labour and ensure timelyprogress in labour and ensure timely
referralreferral
Diagnosis of obstructed labourDiagnosis of obstructed labour