WHO Partograph For Beginner

Dr Muhammad El Hennawy
Ob/gyn specialist
Rass el barr central hospital and
dumyat specialised hospital
Dumyatt – EGYPT
www.mmhennawy.8k.com
Partograph
A partograph is a graphical record of the observations made of a women in labour
For progress of labour and salient conditions of the mother and fetus
It was developed and extensively tested by the world health organization WHO
History Of Partogram
Friedman's partogram devised in 1954 was based on observations of cervical dilatation and foetal station against time elapsed in hours from onset of labour. The time 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. Limits of normal were defined
Philpott and Castle
in 1972 introduced the concept of "ALERT" and "ACTION" lines. The aim of this study was to fulfill the needs of paramedical personnel practising obstetrics in Rhodesian African primigravidae. The alert line represented the mean rate of progress of the slowest 10% of patients in the African population whom they served. 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.
The action line was subsequently drawn two hours to the right of the alert line 
Studd's labour stencils
It were introduced in 1972. These stencils predicted the expected pattern of progression of labour based on the extent of dilataton achieved by the time the patient is admitted (zero time). Curves showing the average course of cervical dilatation were constructed for various dilatation on admission. Five separate patterns representing normal labour progression were constructed. The curves were transcribed onto acrylic stencils On admission in labour, the cervical dilatation was assessed and a stencil was used to draw the relevant pencil line of expected progress on the patient's cervicograph which was then completed. Those crossing the nomogram line were found to have a three fold increase in instrumental delivery.
WHO partograph
Overview
The partograph can be used by health workers with adequate training in midwifery who are able to :
- observe and conduct normal labour and delivery.
- Perform vaginal examination in labour and assess cervical diltation accurately
- plot cervical diltation accurately on a graph against time
There is no place for partograph in deliveries at home conducted by attendants other than those trained in midwifery
Whether used in health centers or in hospitals , the partograph must be accompanied by a program of training in its use and by appropriate supervision and follow up
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 terminjation of labour
increase the quality and regularity of all observations of mother and fetus
early recognition of maternal or fetal problems
the partograph can be 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.).
Partograph function
The partograph is designed for use in all maternity settings , but has a different level of function at different levels of health care
in health center, the partograph,s critical function is
to give early warning if labour is likely to be prolonged and to indicate that the woman should be transferred to hospital (ALERT LINE FUNCTION )
in hospital settings, moving to the right of alert line serves as a warning for extra vigilance , but the action line is the critical point at which specific management decisions must be made
other observations on the progress of labour are also recorded on the partograph and are essential features in management of labour
Components of the partograph
Part 1 : fetal condition ( at top )
Pqrt 11 : progress of labour ( at middle )
Part 111 : maternal condition ( at bottom )
Outcome : ………………
Part 1 : Fetal condition
this part of the graph is used to monitor and assess fetal condition
1 - Fetal heart rate
2 - membranes and liquor
3 - moulding the fetal skull bones
Caput
Fetal heart rate
Basal fetal heart rate?
< 160 beats/mi =tachycardia
> 120 beats/min = bradycardia
>100 beats/min = severe bradycardia
Decelerations? yes/no
Relation to contractions?
Early
Variable
Late – -----Auscultation - return to baseline
> 30 sec  contraction
----- Electronic monitoring
peak and trough (nadir)
 > 30 sec
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
moulding the fetal skull bones
Molding is an important indication of how adequately the pelvis can accommodate the fetal head
increasing molding 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 0 ……………………...++
severely overlapping bones ( non – reducible ) ……..+++
part11 – progress of labour
. Cervical diltation
Descent of the fetal head
Fetal position
Uterine contractions

this section of the paragraph has as its central feature a graph of cervical diltation against time
it is divided into a latent phase and an active phase
latent phase :

it starts from onset of labour until the cervix reaches 3 cm diltation
once 3 cm diltation is reached , labour enters the active phase
lasts 8 hours or less
each lasting < 20 sceonds
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 3 cm diltation represents the rate of diltation of 1 cm / hour
Moving to the right or the alert line means referral to hospital for extra vigilance
Action line ( hospital 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
Cervical diltation
It is the most important information and the surest way to assess progress of labour , even though other findings discovered on vaginal examination are also important
when progress of labour is normal and satisfactory , plotting of cervical diltation remains on the alert line or to left of it
if a woman arrives in the active phase of labour , recording of cervical diltation starts on the alert line
when the active phase of labor begins , all recordings are transferred and start by pltting cervical diltation on the alert line

Descent of the fetal head
It should be assessed by abdominal examination immediately before doing a vaginal examination, using the rule of fifth to assess engagement
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 engage , and by vaginal examination , the lowest part of vertex has passed or is at the level of ischial spines
Assessing descent of the fetal head by vaginal examination; 0 station is at the level of the ischial spine (Sp). 
Occiput transverse positions 
Uterine contractions
Observations of the contractions are made every hour in the latent phase and every half-hour in the active phase
frequency how often are they felt ?
Assessed by number of contractions in a 10 minutes period

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