LABOUR MONITORING BY WHO PARTOGRAPH BY DR SHASHWAT JANI

1. DR SHASHWAT JANI
M.s. ( gynec )
Assist. Prof., Smt. N.H.L. MEDICAL COLLEGE,
AHMEDABAD.
Mobile : +91 99099 44160.
E- mail : drshashwatjani@gmail.com

2. WHY MONITOR?
 The intrapartum period is probably the most
dangerous and traumatic period – a time
associated with a high mortality and morbidity
for both mother and child.
 Maternal and fetal monitoring are essential to
pick up problems early and thus institute timely
intervention.
 Eternal alertness for abnormalities essential –
“a labour is only said to be normal after it is over”

3. INTRODUCTION
 A partograph is a composite graphical record
of the observations made of a woman in labour
on a single sheet of paper.
 It was developed and extensively tested by the
World Health Organization (WHO 1994).
 Can serve as an “early warning system” & assist
in making timely decisions on transfers
(referrals), intervention (augmentation) &/or
termination of pregnancy.

4. HISTORY
 Emanuel Friedman's partograph - 1954
 Based on observations of cervical dilatation and
foetal station against time elapsed in hours from
onset of labour.
 The time of onset of labour was based on the
patient's subjective perception of her
contractility.
 Plotting cervical dilatation against time yielded
the typical Sigmoid or 'S' shaped curve, and
station against time gave rise to the Hyperbolic
curve.

6. Philpott and Castle – 1972
 Introduced concept of "ALERT" and "ACTION"
lines.
 Alert line was drawn at a slope of 1
centimetre/hr for nulliparous women starting at
zero time i.e. time of admission .
 Action line drawn four hours to the right of
the alert line showing that if the patient has
crossed the alert line active management should
be instituted within 4 hours, enabling the
transfer of the patient to a specialised tertiary
care centre.

8. Studd's labour stencils - 1972
 Five separate patterns representing normal
labour progression were constructed.
 The curves were transcribed onto acrylic
stencils.

9. OTHER PARTOGRAPHS
 Hand drawn – Paper & Pencil.
 Round partograph.
 E – partograph.

10. PARTOGRAPH

11. OBJECTIVES
 Early detection of abnormal progress of labour.
 Prevention of prolonged labour.
 Recognize cephalopelvic disproportion long
before obstructed labour.
 Assist in early decision on transfer,
augmentation, or termination of labour.

12. OBJECTIVES (cont..)
 Increase the quality and regularity of all observations of
mother and fetus.
 Early recognition of maternal or fetal problems.
 Highly effective in reducing complications from
prolonged labor for the mother (postpartum
hemorrhage, sepsis, uterine rupture and its sequelae)
and for the newborn (death, anoxia, infections, etc).
 Reduce incidence of CS rate.
 Facilitates handover procedure.

13. COMPONENTS
 Part I : Patient Identification
 Part II : Fetal condition
 Part III : Progress of labour
 Part IV : Maternal condition
 Outcome………………

14. Part I : PATIENT IDENTIFICATION
 Name
 Gravida
 Para
 Hospital number
 Date and time of admission
 Time of ruptured membranes.

15. Part II : FETAL CONDITION
 Monitor and assess fetal condition
1 - Fetal heart rate
2 - Liquor
3 - Moulding the fetal skull bones

16. FETAL HEART RATE
 Monitor every 30 mins in latent phase.
 Every 15 mins in active phase.
 Every 5 mins in 2nd stage of labour.
 Mark it with a dot & join the lines.
Basal fetal heart rate?
 < 160 beats/min =tachycardia
 > 110 beats/min = bradycardia
 >100 beats/min = severe bradycardia

17. MEMBRANES AND LIQUOR
 Intact membranes ……………………………….. I
 Ruptured membranes + clear liquor ……………… C
 Ruptured membranes + meconium- stained liquor.. M
 Ruptured membranes + blood – stained liquor…… B
 Ruptured membranes + absent liquor……………. A

18. 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.
 Separated bones, sutures felt easily …………….… O
 Bones just touching each other …………………… +
 Overlapping bones (reducible)…………………... ++
 Severely overlapping bones (nonreducible) …….. +++

20. Part III : PROGRESS OF LABOUR
 Cervical dilatation
 Descent of the fetal head
 Uterine contractions
 Fetal position

21.  This section of the partograph has as its central
feature a graph with a vertical scale on the left,
numbered in the ascending order from 0 to 10
(Cervical dilatation in cms).
 In same vertical scale – descent of the fetal head
as assessed by abdominal examination.
 At the right in the descending order denotes the
station of the fetal presenting part.

23.  Horizontal scale represents hours spent in
labour.
 Points are entered as a cross (x) for cervical
dilatation & station by a dot (•).
 Each observation is joined to the preceding one
by a straight line.
 The ‘S’ shaped dilatational curve is divided into a
latent phase and an active phase.

24. LATENT PHASE
 It starts from onset of labour until the cervix
reaches 3 cm dilatation.
 Once 3 cm dilatation is reached, labour enters
the active phase.
 Lasts 8 hours or less.
 At least 2/10 min contractions.
 Each lasting < 20 seconds.

25. ACTIVE PHASE
 Contractions at least 3 / 10 min
 Each lasting < 40 seconds
 The cervix should dilate at a rate of 1 cm / hour
or faster.
 Further subdivided into –
 Acceleration phase – 2.5 – 4 cms.
 Phase of maximum slope – 4 – 9 cms.
 Deceleration phase – 9 – 10 cms.

27.  This can also be divided into 3 functional
divisions –
1. Preparatory division – Including latent &
acceleration phase.
2. Dilatation division – Phase of maximum slope.
3. Pelvic division – Deceleration phase.

28. ALERT LINE
 The alert line drawn from 3 cm dilatation
represents the rate of dilatation of 1 cm/hour.
 In a normal labour, cervical dilatation should be
either on the alert line or to the left of it.
 Moving to the right of the alert line means it
falls on zone 2, it is abnormal & needs to be
critically assessed.

29. ACTION LINE
 The action line is drawn 4 hours to the right of
the alert line and parallel to it.
 This is the critical line at which specific
management decisions must be made.
 When it falls in zone 3 case should be reassessed
by a senior person. Decision to be made for CS
or augmentation of labour.

31. CERVICAL DILATATION
 It is the most important information
and the surest way to assess progress of
labour.
 When progress of labour 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 labour, recording of cervical
dilatation starts on the alert line.

33. CERVICAL DILATATION (cont..)
 When the active phase of labor begins, all
recordings are transferred and start by plotting
cervical dilatation on the alert line using the
letters TR.
 Leaving the area between the transferred
recording blank. The broken transfer line is not
part of the process of labor.
 Do not forget to transfer all other findings
vertically.

35. DESCENT OF THE FETAL HEAD
 It should be assessed by abdominal examination
immediately before doing a vaginal examination,
using the Rule of fifth ( Crichton method ) to
assess engagement.
 The rule of fifth means the palpable fifth of the
fetal head is felt by abdominal examination
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.

37. DESCENT OF THE FETAL HEAD (cont..)
 By vaginal examination, the lowest part of vertex
has passed or is at the level of ischial spines in
absence of caput, is said to be engaged head.

38. FETAL POSITIONS
 Occiput transverse positions
 Occiput anterior positions

40. UTERINE CONTRACTIONS
Palpate number of contractions in ten
minutes and duration of each contraction in
seconds
 Less than 20 seconds:
 Between 20 and 40 seconds:
 More than 40 seconds:

41.  Observations of the contractions are made every
hour in the latent phase and every half-hour in
the active phase.
 Assessed by number of contractions in a 10
minutes period.
 Measured in seconds from the time the
contraction is first felt abdominally, to the time
the contraction passes off.
 Each square represents one contraction.

43. Part IV: MATERNAL CONDITION
Assess maternal condition regularly by monitoring:
 Oxytocin – Amount per volume IV fluids in
drops per minute, every 30 mins. Conc in upper
box & dose (mIU/min) in lower box.
 Drugs – Any additional drugs given.
 IV Fluids – used.

44. Part IV: MATERNAL CONDITION
 Pulse – Every 30 mins & marked with a dot (•).
 Blood pressure – Recorded in vertical line every
4 hours & marked with arrows.
 Temperature – Recorded every 2 hours.
 Urine volume , analysis for protein and acetone
– Everytime urine is passed.

46. MANAGEMENT OF
LABOUR USING THE
PARTOGRAPH

47. - Latent phase is less than 8 hours
- Progress in active phase remains on or
to the left of the alert line.
 Do not augment with oxytocin if latent and
active phases go normally.
 No ARM in latent phase.
 ARM at any time in active phase.

48. Between alert and action lines
 In health center, the women must be
transferred to a hospital with facilities for
caesarean section, unless the cervix is almost
fully dilated.
 Observe labor progress for short period
before transfer.
 Continue routine observations.
 ARM may be performed if membranes are
still intact.

49. At or beyond action line
 Conduct full medical assessment.
 Consider intravenous infusion / bladder
catheterization / analgesia.
 Options
- Deliver by caesarean section if there is fetal
distress or obstructed labour.
- Augment with oxytocin by intravenous infusion if
there are no contraindications.

50. ABNORMAL PROGRESS OF
LABOR

51. “ One of the main functions of the
partograph is to detect early
deviation from normal progress of
labor. “

52. LABOUR TIME FRAMES
Phases/ Stages of labour Nulliparous Multiparous
Latent phase Mean time 6.4 h 4.8 h
Longest 20.1 h 13.6 h
Active phase Mean rate 3 cm/h 5.7cm/h
Slowest 1.2cm/h 1.5cm/h
2nd Stage Mean time 1.1 h 0.4 h
Longest 2.9 h 1.1 h

53. LATENT PHASE
 Normal duration – 8hrs in Primi & 4hrs in
Multi.
 This is why there is a heavy line drawn on the
partograph at the end of 8 hours of the latent
phase.

54. PROLONGED LATENT PHASE
 It is prolonged when its duration exceeds 20 hrs
in Primi & 14 hrs in Multi.
 According to WHO partograph, a prolonged
latent phase is “Cervix not dilated beyond 4cms
after 8hrs from admission & with any changes in
cervical effacement or dilatation.”

56. PROLONGED ACTIVE PHASE
 In the active phase of labor, plotting of cervical
dilatation will normally remain on or to the left of
the alert line.
 Moves to the right of the alert line warns that
labor may be prolonged.
 Happens if the rate of cervical dilatation in active
phase of labor is less than 1cm/hour for a
minimum of 4hrs.
 At the action line, the woman must be carefully
reassessed for why labor is not progressing and a
decision made on further management.

58. PROLONGED DECELERATION
PHASE
 Deceleration phase exceeds 3 hrs for nulliparas
& 1 hour for multiparas.

59. SECONDARY ARREST OF
CERVICAL DILATATION
 When the cervical dilatation commences
normally but stops or slows significantly for 2
hours or more prior to full dilatation of cervix.

61. SECONDARY ARREST OF HEAD
DESCENT
 Abnormal progress of labor may occur with
normal progress of descent of the fetal head
then followed by secondary arrest of descent of
fetal head.

62. Diagnostic Criteria
( In active labour)
 For Protracted dilatation, criteria are
less than 1.2 cm per hour for primips and
less than 1.5 cm per hour for multips.
 For Protracted descent, the criteria are
less than 1.0 cm per hour in primips and
less than 2.0 cm per hour for multips.

64. PRECIPITATE LABOUR
- Maximum slope of dilatation of 5 cm/hr or
more

65. POINTS TO REMEMBER

66.  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.

67.  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.
 Fill up the patient details. Note the FHR &
colour of liquor.

68.  If progress of labor is satisfactory, the plotting
of cervical dilatation will remain at or to the left
of the alert line.
 When labor progresses well , the dilatation
should not move to the right of the alert line.
 The latent phase 0 – 2 cm dilatation, is
accompanied by gradual shortening of cervix.
Normally, the latent phase should not last more
than 8 hours.

69.  The active phase, 3 – 10 cm dilatation, should
progress at a rate of at least 1 cm/hour.
 When the woman arrives in the latent phase,
time of admission is 0 time.
 When admission takes place in the active phase ,
the admission dilatation, is immediately plotted
on the alert line.

70.  Dilatation of the cervix is plotted/recorded with
a (x), descent of the fetal head is plotted with a
(•) 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).

71.  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).

72.  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.
 When a woman’s 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.

73.  When a woman in labor passes the latent phase
in less than 8 hours i.e., transfers from latent to
active phase, the most important feature is to
transfer plotting of cervical dilatation to the alert
line using the letters TR.
 Note down the oxytocin conc & dose, drugs &
iv fluids. Pulse, BP, Urine examination &
Temperature.

74. ELECTRONIC
PARTOGRAPH

75.  A method of monitoring the progress of labor
in a mother during childbirth, by attaching a
position sensor to a predetermined point on the
mother's pelvic bones; monitoring the location
of the position sensor in three- dimensional
space relative to a reference; and monitoring the
location of the fetal presenting part with respect
to the predetermined point on the mother's
pelvic bones.

76.  The location of the fetal presenting part may be
indicated by a similar position sensor, or by
imaging. Other conditions, such as effacement,
cervical dilatation, and cervical position may also
be monitored in a similar manner.

77. Full electronic capture of patient information
during childbirth including -
 CTG,
 Partograph,
 All labour events,
 Outcome information.

78.  Fetal blood sampling results and cord blood
gases direct from the blood gas analyzer.
This information can be shown in real time to
enhance communication within and outside the
delivery suite to improve patient care and reduce
human error.
 It can be accessed from anywhere, anytime,
from within a hospital or from home..

79. COMPUTERIZED LABOUR
MANAGEMENT
To accurately and continuously measure cervical
dilatation and fetal head station in labor and the
fetal monitoring and maternal monitoring.
An ultrasound–based computerized labor
management system was designed -
The Fetal Monitoring System and
The Maternal Monitoring System with
The system´s in-vivo generated individual
Partographs with real time dilatation and head
station measurements.

80.  The measurements had accuracy of ≤ 5mm.
 All parturients were comfortable throughout the
insertion and the testing period.
 There was no infection, bleeding or any
significant local complication at any attachment
site.

81.  This system provides accurate continuous
measurements of dilatation and station.
 The method is superior to digital examination
and provides real time diagnosis of non-progressive
and precipitous labor.
 The system is likely to reduce discomfort and
infections associated with multiple vaginal
examinations..

83.  The Fetal Monitoring System
Is a computer based training system that can be
accessed from anywhere, anytime, from within a
hospital or from a home.

84.  The Maternal Monitoring System -

85. WHO PARTOGRAPH

86.  The WHO partograph has been modified in
2000 to make it simpler and easier to use.
 The latent phase has been removed
and plot t ing on the par tograph
begins in the act ive phase when the
cervix is 4 cms di lated.

88. Modified partograph - Indonesia
 – 626 women; 20 midwives
 – Referral rate increased
 – Fewer vaginal exams
 – Fewer augmented labour
 – Fewer obstructed labour
(World Bank Tokyo April , 2010)

89. ADVANTAGES
 Inexpensive technology which does not
malfunction.
 A picture is worth a thousand words.
 Helps in continuity of care and providing
information.
 Easy Handover Procedure.
 No major capital investment other than skilled
attendant.

90.  Documented evidence for Medico Legal
purpose.
 Educational value for all grades of staff.

91. DISADVANTAGES
 Assumes that all women progress at same rate
– May influence intervention rate.
 Clinical findings have subjective variations.
 Loss of clinical autonomy.
 Lack of knowledge.
 Non availability of printed partographs.
 Duplication of recording.