A partograph is a graphical tool used to monitor fetal condition, maternal condition, and labor progress during the active first stage of labor. It helps detect abnormalities and informs decisions about necessary interventions.

Note: The partograph is only used during the active first stage of labor (when the cervix is 4cm or more dilated and there are regular contractions) for recording salient conditions of the mother and fetus.

Uses of Partograph

1. Detect abnormal labor progress: Identify when labor is not progressing as expected.

2. Guide augmentation: Determine when augmentation of labor is appropriate.

3. Recognize cephalopelvic disproportion (CPD): Identify CPD when obstruction occurs.

4. Improve quality of care: Enhance the quality of observations on the mother and fetus during labor.

5. Early warning system: Serve as an “early warning system” for potential problems.

6. Inform decisions: Assist in making timely decisions regarding transfer or augmentation.

Who Should Not Use a Partograph?

• Women with identified problems before or during labor that require special attention.

• Women not anticipating a vaginal delivery (e.g., those scheduled for an elective cesarean section).

Parts of a Partograph

A partograph has three main parts:

1. Fetal Condition

2. Maternal Condition

3. Labor Progress

Observations Charted on a Partograph

1. Labor Progress

• Cervical Dilatation: Assessed every 4 hours via vaginal examination (VE).

• Descent of Presenting Part: Assessed every 2 hours via abdominal palpation.

• Uterine Contractions: Assessed every 30 minutes for frequency, duration and strength.

2. Fetal Condition

• Fetal Heart Rate: Assessed every 30 minutes (or more frequently if abnormal).

• Membranes and Amniotic Fluid: Assessed every 4 hours, especially after rupture.

• Molding of the Fetal Skull: Assessed every 4 hours during a VE.

3. Maternal Condition

• Pulse: Assessed every 30 minutes.

• Blood Pressure: Assessed every 2 hours.

• Respiration and Temperature: Assessed every 4 hours.

• Urine: Volume assessed every 2 hours; also test for acetone, protein, and glucose.

• Drugs and IV Fluids: Record administration, including oxytocin, if applicable.

Starting a Partograph

The partograph should only be started when a woman is in the active phase of labor, defined by:

• Regular contractions: At least one or more contractions in 10 minutes.

• Cervical dilatation: 4 cm or more.

Partograph Components

FETAL CONDITION

1. Fetal Heart Rate:

   • Normal range: 120-160 beats per minute (bpm).

   • Assess every 30 minutes, or every 15 minutes if abnormal.

   • If the fetal heart rate remains abnormal for three consecutive observations, take action.

   • Below 120 bpm or above 160 bpm may indicate fetal distress.

2. Molding:

   • Assessed during a VE and graded as follows:

     State of Molding	Record
     Absence of molding	(-)
     Bones are separate, and sutures are felt	(0)
     Bones are just touching each other	(+)
     Bones are overlapping but can be separated	(++)
     Bones are overlapping but cannot be separated	(+++)

3. Amniotic Fluid (Liquor):

   • Observed after spontaneous or artificial rupture of membranes.

   • Note the color and consistency:

     State of Liquor	Record
     Clear (normal)	(C)
     Light green in color	(m+)
     Moderate green, more slippery	(m++)
     Thick green, meconium stained	(m+++)
     Blood stained	(B)

4. Membranes:

   State of Membranes	Record
   Intact	(I)
   Ruptured	(R)

LABOR PROGRESS

1. Cervical Dilatation:

   • Plotted with an “X” on the graph.

   • Usually, recording starts at 4 cm.

   • Alert Line: Starts at 4 cm and extends to the point of expected full dilatation (10 cm) at a rate of 1 cm per hour.

   • Action Line: Parallel to the alert line, 4 hours to the right.

2. Descent of the Presenting Part:

   • Assessed by abdominal palpation and measured in fifths above the pelvic brim.

   • Use the width of five fingers as a guide to estimate the portion of the fetal head above the brim.

   • A ballotable head will accommodate five fingers above the brim.

   • As the head descends, fewer fingers will fit above the brim.

   • The head is considered engaged when 2/5 or less is above the brim.

   • Plotted with an “O” on the graph.

3. Uterine Contractions:

   • Assessed every 30 minutes.

   • Note the frequency, duration, and strength of contractions within a 10-minute period.

   • Mild: Less than 20 seconds.

   • Moderate: 20-40 seconds.

   • Strong: More than 40 seconds.

   • Use the following symbols on the partograph:

     • Dots: Mild contractions

     • Diagonal Lines: Moderate contractions

     • Shading: Strong contractions

Maternal Condition

1. Pulse:

   • Assess every 30 minutes.

   • Normal range: 70-90 bpm.

   • Elevated pulse may indicate maternal distress or infection (especially with prolonged rupture of membranes).

   • Low pulse may indicate maternal collapse.

2. Blood Pressure:

   • Assess every 2 hours.

   • Normal range: 90/60 – 140/90 mmHg.

   • An increase of 30 mmHg systolic or 20 mmHg diastolic from the baseline, or if persistently elevated after three readings, test urine for protein to rule out pre-eclampsia.

3. Temperature:

   • Assess every 4 hours.

   • Normal range: 36.5°C – 37.5°C (97.7°F – 99.5°F)

   • Elevated temperature may indicate infection, dehydration, or maternal distress, especially with early rupture of membranes.

4. Urine:

   • Encourage the mother to urinate at least every 2 hours.

   • Test urine on admission for protein, glucose, and ketones.

5. Fluids:

   • Encourage the mother to drink at least 250-300 ml of fluids every 30 minutes (except alcohol). Sweetened fluids can provide energy.

Further Management in the Normal First Stage of Labor

Nursing Care

1. Emotional Support:

   • Provide reassurance and keep the mother informed about her progress.

   • Allow her to talk to relatives and her husband.

   • Rub her back to relieve pain.

   • Allow ambulation or sitting in bed if the membranes are intact.

   • Allow her to read or engage in other distracting activities if desired.

2. Nutrition:

   • Encourage light, easily digestible foods like soup, bread, and sweet tea to provide energy and hydration.

3. Elimination:

   • Encourage the mother to empty her bladder every 2 hours.

   • Measure and test each urine specimen.

   • Pass a catheter if the mother is unable to urinate.

4. Personal Hygiene:

   • Allow the mother to bathe on admission or in early labor if her condition permits.

   • Provide clean perineal pads after membrane rupture and encourage frequent changes.

   • Perform vulvar swabbing using aseptic techniques.

5. Ambulation and Position:

   • Encourage ambulation in early labor to aid descent.

   • During contractions, have the mother lean forward, supporting herself on a chair or bed.

   • Allow the mother to adopt any comfortable position except the supine position.

   • Confine the mother to bed when the membranes rupture in the advanced stage of labor.

6. Prevention of Infection:

   • Maintain strict aseptic techniques during VE and vulval swabbing.

   • Perform vulval toileting every 4 hours after membrane rupture.

   • Administer antibiotics if the membranes rupture early to prevent ascending infection.

   • Change bed linens frequently.

   • Maintain good hand hygiene.

7. Rest and Sleep:

   • Encourage the mother to rest between contractions.

What to Report

• Abnormalities in urine (protein, glucose, ketones).

• Inability to pass urine.

• Elevated temperature, pulse, or blood pressure.

• Hypertonic uterine contractions.

• Meconium-stained amniotic fluid (grade 2 or 3) after membrane rupture.

• Failure of the presenting part to descend despite good contractions.

• Abdominal tenderness.

• Vaginal bleeding.

• Decreased blood pressure.

• Elevated fetal heart rate.

Complications

• Infections

• Early rupture of membranes

• Cord prolapse

• Supine hypotensive syndrome

• Fetal distress

• Maternal distress

• Antepartum hemorrhage (APH)

• Preeclampsia and eclampsia

• Prolonged labor

• Obstructed labo