A Practical Guide for Health Care Workers

THE PARTOGRAPH IN UGANDA

A PRATICAL GUIDE FOR

HEALTH CARE WORKERS

Prepared by: Reproductive Health division, Ministry of Health

THE REPUBLIC OF UGANDA

Ministry of Health

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TABLE OF CONTENTS
Page
TABLE OF CONTENTS...........................................................................................................1
1.0. INTRODUCTION FOR USERS.......................................................................................2
1.1. WHICH WOMEN SHOULD HAVE A PARTOGRAPH IN LABOUR?.......................2
1.2. WHICH WOMEN SHOULD NOT HAVE A PARTOGRAPH?.....................................2
2.0. OBJECTIVES OF THIS TRAINING GUIDE:...............................................................2
3.0. OBSERVATIONS CHARTED ON THE PARTOGRAPH:.............................................3
Progress of labour:.............................................................................................................3
The foetal condition:..........................................................................................................3
The maternal condition:.....................................................................................................4
3.2. Latent and Active Phases of Labour:...........................................................................4
3.2.1 Latent Phase……………………………………………………………………….4
3.2.2 Active Phase………………………………………………………………………4
3.2.3. Cervical dilatation:..................................................................................................7
3.2.4. Descent of the foetal head:.......................................................................................8
3.2.5. Uterine Contractions...............................................................................................9
3.2.6: The Foetal conditions:...........................................................................................11
4.0. ABNORMAL PROGRESS OF LABOUR.......................................................................14
5.0. MANAGEMENT OF LABOUR......................................................................................15
6.0 CONCLUSION.................................................................................................................16
ANNEX I: CASE STUDY.....................................................................................................17

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1.0. INTRODUCTION FOR USERS

This guide will help you in the management of labour. A Partograph is used to record all
observations made on a woman in labour. Its central part is a graph, where dilatation of the
cervix and the descent of the presenting part is plotted. By noting the rate at which the cervix
dilates, it is possible to identify women whose labours are abnormally slow and require
special attention e.g. prolonged and obstructed labour due to cephalopelvic disproportion
(CPD). This may lead to serious problems such as uterine rupture and death of the foetus.
Other problems that may result from slow progress in labour include postpartum haemorrhage
and infection. By helping to identify at an early stage those women whose labour is slow, the
Partograph should prevent some of these problems. It is a clear way of recording all labour
observations on one chart, making it easy to detect any emerging abnormalities.

1.1. WHICH WOMEN SHOULD HAVE A PARTOGRAPH IN LABOUR?

Every mother committed to a vaginal delivery should have a Partograph recorded. These
include singleton cephalic presentations, breech presentations and multiple pregnancy. The
Partograph is a tool for managing labour. It does not help to identify other risk factors which
are already present.

1.2. WHICH WOMEN SHOULD NOT HAVE A PARTOGRAPH?

The Partograph should not be used for women arriving in the 2 nd stage of labour or those for
Caesarean section.

2.0. OBJECTIVES OF THIS TRAINING GUIDE:

After the orientation course, the Doctor, Clinical Officer, and midwifery personnel should be
able to:
 Explain the concept of the Partograph
 Record observations accurately on the Partograph
 Interpret a recorded Partograph and recognise any deviation from normal labour.

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 Monitor the progress of labour, recognise the need for action at the right time and
decide on interventions or timely referral.
 Explain to mothers and community members the usefulness of the Partograph.

3.0. OBSERVATIONS CHARTED ON THE PARTOGRAPH:

3.1. Definition of labour:

Labour is the occurrence of regular painful contractions in a pregnancy which is over 28

completed weeks and above of gestation causing progressive cervical effacement and
dilatation.

Progress of labour:

This is assessed by:

 Cervical dilatation
 Descent of the foetal head
 Uterine contractions:
 Frequency in 10 minutes and
 Duration (shown by differential shading)
 Vaginal examination in active labour is performed every 4 hours before 7 cm or when
membranes rupture spontaneously (to exclude cord prolapse).
 Vaginal examination can also be done as appropriate:
a) after 3 hours if cervical dilatation is 7 cm
b) after 2 hours if cervical dilatation is 8 cm
c) after 1 hour if cervical dilatation is 9 cm
d) When the mother starts bearing down.
The foetal condition:
This is monitored by:
 Foetal heart rate after every 30 minutes
 State of membranes and colour of the liquor
 Moulding of the skull bones
 Caput formation

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The maternal condition:

This is assessed in the following ways:

 Pulse, blood pressure and temperature
 Urine (Volume. Protein, acetone)
 Drugs and IV fluids (including Oxytocin)
 Her behaviour and attitude e.g. very anxious, distressed
 Material (non-medical) care given to her e.g. toilet and bathroom facilities, feeding,
light, etc.

3.2. Latent and Active Phases of Labour:

The first stage of labour is divided into the latent and active phases.

3.2.1. Latent Phase:

The latent phase of labour lasts from the onset of cervical dilatation to when the cervix is 4 cm
dilated. Patients who get regular painful contractions timed by an observer at a frequency of at
least 2 in 10 minutes of duration of 20 seconds but cervical dilatation is less than 4 cm are
described as being in latent phase of labour. Don not plot a Partograph but vital signs and
foetal heart rate should be monitored every hour and recorded.

In the clinical notes, if this pattern of contractions continues for more than 8 hours and there is
no progressive dilatation of the cervix, the mother should be reviewed to decide on further
management.

3.2.2 Active Phase:

The active phase (period of faster cervical dilation) is from 4 cm to 10 cm (full cervical
dilation).

A Partograph is started for a pregnancy of at least 30 completed weeks. No partograph should

be started for women admitted at 9 cm or 10 cm dilated.

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Use provided Partograph

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Starting the Partograph

 Only start a Partograph when you have checked that there are no complications
of the pregnancy that require immediate action.
 A Partograph chart must be started when a woman is in the active phase of
labour.
 You must start plotting a partograph when the woman is 4 or more cm in active
phase of labour.
 In the active phase, contractions must be 1 or more in 10 minutes, each lasting 40
seconds or more.
 The foetus is presenting cephalic or breech.

3.2.3. Cervical dilatation:

The rate of cervical dilatation changes from the latent to active phase of labour. In the centre
of the Partograph is a graph. Along the left are numbers 0 – 10 against squares. Each square
represents 1 cm dilatation. Along the bottom of the graph are numbers 0 – 16; each square
represents 1 hour. Dilatation of the cervix is measured in centimetres (cm).

The dilatation of the cervix is plotted with an “x”. The first vaginal examination, on
admission, includes a pelvic assessment and the findings are recorded under Clinical notes.

Examples of plotting cervical dilatation when the Mother is in active phase of

Admission:

Look at Fig 1. There is “alert” line, a straight line between 4 and 10 cm. When a woman is
admitted in the active phase, the dilatation of the cervix is plotted on the alert line and the
clock time written directly under the x in the space for time.

 If progress is satisfactory, the plotting of cervical dilatation will remain on the left of
the alert line.

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Exercise:
Mrs. Musoke had the following findings:
 Dilatation of the cervix was 4 cm on admission in the active phase of labour
 Dilatation is plotted on the alert line at 4 cm using “x”
 The time of admission was 15.00
 At 17.00 the dilatation was 10 cm
 Time in the first stage of labour in the hospital was only 2 hours.
Plot the above findings on a graph.

Points to remember

Do not start to plot when admission is in the latent phase. Perform a vaginal
examination every 4 hours and start the Partograph when the dilatation is 4 cm or more.

 The latent phase is from 0-4 cm dilatation and is accompanied by gradual

shortening of the cervix. It should normally last less than 8 hours.
 The active phase is from 4-10 cm and dilatation should be at least 1cm/hour.
 When labour progresses well, the dilatation should be on alert line and should not
go to the right of the line.
 When admission to the health facility takes place in the active phase, the
admission dilatation is immediately plotted on the alert line.
 When admission to hospital takes place in the latent phase, the admission
dilatation is not plotted until it is 4 cm or more.

3.2.4. Descent of the foetal head:

For labour to progress well, dilatation of the cervix should be accompanied by descent of the
head. However, descent may not take place until the cervix has reached about 7 cm dilatation.

Descent of the head is measured by abdominal palpation and expressed in terms of fifths
above the pelvic brim.

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It is generally accepted that the head is engaged when the portion above the brim is 2 fingers
wide (2/5).

Descent is plotted with an “O” in the Partograph.

 Descent of the foetal head is one of the important indicators of the progress of labour.
 It is assessed abdominally in fifths felt above the pelvic brim.
 Descent of the foetal head should always be assessed every two hours by abdominal
examination.

5/5 4/5 3/5 2/5 1/5 0/5

S
S
S
O S
O S
O
Pelvic brim S
O
O
O

Key:
(Pelvic Cavity)
Completely Sinciput Sinciput Sinciput Sinciput None of S:
above High Easily felt Felt felt Occiput head
Occiput Occiput Occiput not felt palpable
Sinciput
Easily felt Felt Just felt

Fig. 2.
3.2.5. Uterine Contractions

For labour to progress well, there must be good uterine contractions. In normal labour
contractions become more frequent and last longer as labour progresses.

Observing uterine contractions is necessary every hour in the latent phase of labour and every
half-hour in the active phase.

There are two observations made about contractions:

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1. The frequency: how often are they felt?

2. The duration: how often do they last?

The frequency of contractions is assessed by the number of contractions in a 10 minutes

duration every half hour.

The duration of the contractions is from the time the contraction is first felt abdominally to the
time when the contraction passes off, measured in seconds.

Recording contractions on the Partograph:

As illustrated on the partograph below the time line, there is an area of 5 blank squares going
across the length of the graph; and at the left hand side is written “contraction per 10
minutes”. Each square represents 1 contraction, so that if 2 contractions are left in 10 minutes,
2 squares will be filled. The duration of contractions is indicated by filling the square as
follows:

LESS THAN 20 SECONDS

BETWEEN 20-40 SECONDS

MORE THAN 40 SECONDS

Fig.3. Example: Plotting frequency of contractions

HOURS 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
TIME

CONTRACTI 5
ONS 4
PER 10 3
2

Observations on Fig 3.

The woman was admitted at 14.00 in the active phase of labour.

Contractions: there was 1 contraction (short) in 10 minutes lasting less than 20 seconds.

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2 Contractions in 10 minutes lasting 20 – 40 seconds.

5 contractions in 10 minutes lasting more than 40 seconds.

Points to remember:

 Contractions are observed for frequency and duration

 The number of contractions in 10 minutes is recorded by shading the square
corresponding to the actual time they have occurred to the woman.
 The duration must be observed too.
 If the woman comes in the latent phase of labour (dilatation smaller than 4 cm),
wait and don’t keep record until she is in the active phase of labour (dilatation of the
cervix greater than 4 cm).
 If the woman comes in the active phase of labour (dilatation greater than 4cm),
recording of the cervical dilatation starts on the alert line.
 When progress of labour is normal, plotting of the cervical dilatation remains on
the alert line or to the left of it.

3.2.6: The Foetal conditions:

3.2.6.1: Foetal Heart rate:

Observing the foetal heart rate is a safe and reliable clinical way of knowing that the foetus is
well. The best time to listen to the foetal heart is just after the contraction has passed. Listen to
the foetal heart for 1 minute in the left lateral position. In normal labour, it is recorded every
thirty minutes and each square represents half an hour. The lines for 120 and 160 are darker, to
remind the recorder that these are the limits of the normal foetal heart rate. In Uganda a wider
working margin has been provided for taking into consideration the problems of referral and
the delays in health facilities to effect definitive management. Therefore even though Uganda
is aware of the WHO Guidance which puts the margin at 100 up to 180 when training health
workers, this will be explained.

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3.2.6.2. Abdominal foetal heart:

A foetal heart rate faster than 160 beats/minute (tachycardia) and slower than 120
beats/minute (bradycardia) or irregular indicates foetal distress and action should be taken
immediately. Please note that in a pre-term baby, a foetal heart of more than 160 bpm may be
normal.

If an abnormal rate is heard, listen every 15 minutes for at least 1 minute immediately after a
contraction. If the heart rate remains abnormal over 3 observations, action should be taken
unless delivery is very close.

3.2.6.3. Membranes and liquor

When membranes are still intact, indicate this with an “I” and an “R” when they have
ruptured. Specify if this was spontaneous (SRM) or artificial (ARM). When membranes have
ruptured, perform a vaginal examination to rule out cord prolapse. Record the time the
membranes ruptured in the upper right side of the client.

C when the liquor is clear

B when it is blood stained
M when the liquor is meconium stained
M when the liquor is dark green stained
M when the liquor is thick greenish stained (breech)
A when liquor is absent

These observations are made at each vaginal examination.

The state of liquor can assist in assessing the foetal conditions. If there is thick meconium at
any time or absent liquor at the time of membrane rupture, listen to the foetal heart more
frequently, as these may be signs of foetal distress.

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3.2.6.4. Moulding of the foetal skull bones:

Moulding is an important indication of how adequately the pelvis can accommodate the foetal
head. Increasing moulding with the head high in the pelvis a sign of cephalopelvic
disproportion.

Moulding is recorded in 4 different ways on the partograph, immediately under the liquor.

Grade O ...............................................If bones are separated and the sutures can be easily felt.
Grade I+..............................................................................If bones are just touching each other
Grade II++............................................................If bones are overlapping and can be separated
Grade III+++....................................If bones are severely overlapping and cannot be separated.

Grade III moulding signifies impending obstruction of labour and spells danger for the baby
and mother warranting immediate intervention. Moulding may be difficult to assess in the
presence of a large caput. However, a caput itself is already a possible sign of cephalopelvic
disproportion.

Points to remember

 Listen to the foetal heart rate immediately after the peak of a contraction with the
woman in the lateral position.
 Recordings are made every half-hour in the first stage of a normal labour or every 15
minutes if labour is abnormal.
 Normal foetal heart is between 120 and 160 beats/minute
 Increasing moulding with a high head is a sign of disproportion
 When membranes rupture, perform a vaginal examination to rule out cord prolapse.
 Smelly liquor may indicate intra-uterine infection.

3.2.7 The Maternal Condition:

This is monitored through:

 Pulse rate every half hour
 Blood pressure once every 4 hours, or more frequently if indicated.

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 Temperature once every 4 hours, or more frequently if indicated.

 Urine: indicated when it is passed and possibly the amount. Urine should be tested for
albumin, sugar and acetone as indicated.

All the above recordings for the condition are centred at the bottom part of the partograph.

3.2.7.1: Drugs and IV fluids:

These are recorded in the appropriate column at the bottom of the chart indicating the doze,
route of administration, type and time of administration. When inducing or augmenting with
Oxytocin, indicate the rate.

4.0. ABNORMAL PROGRESS OF LABOUR

4.1. Prolonged latent phase:

If a woman is admitted in labour in the latent phase (less than 4 cm dilated) and remains in the
latent phase for the next 8 hours, progress is abnormal and she must be examined by a Doctor
for a decision about further action. In a health centre, a woman should be referred where there
are facilities for emergency obstetric care.

3.3. Prolonged active phase:

4.2.1. Moving to the next alert line:

In the active phase of labour, plotting of cervical dilatation will normally remain on, or to the
left of the alert line. But some will move to the right of the alert line and this may be
prolonged. Provided two fifths of the head are palpable above the pelvic brim, it is safe to
perform artificial rupture of membranes. In case you find M+++, grade III moulding or a
caput, take appropriate action.

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4.2.2. At the action line:

The action line is 4 hours to the right of the alert line, if a woman’s labour reaches this line, a
decision must be made about the cause of the slow progress, and appropriate action taken.
This decision and action must be taken in a health unit with facilities to deal with obstetric
emergencies.

Points to remember

 Allow women whose partograph moves to the right of the alert line must be
carefully monitored in an institution with adequate facilities or referred to a health
facility well equipped to handle emergencies.
 At the action line the woman must be fully reassessed and a decision made on
further management.

5.0. MANAGEMENT OF LABOUR

The following is suggested protocol for labour management.
5.1. Normal active phases
 Active phase remains on or to the left of the alert line
 Do not augment with Oxytocin or intervene unless it is necessary
 Artificial rupture of membranes (ARM) must not be done in latent phase of labour.
 ARM at any moment in the active phases is carried out when indicated and caution
must be observed where the mother is HIV positive or suspected.
5.2. Action line or beyond (In a health unit with emergency obstetric care)
Re-assess the patient and consider the following options:
 Intravenous fluids, bladder catheterisation, analgesics
 Vaginal examination must be done by experienced midwife or by doctor depending on
dilatation
 Oxytocin augmentation by intravenous infusion, while on Oxytocin infusion the
mother must be checked at least every 15 minutes for vital signs.
 Consider delivery by caesarean section

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Points to remember

 Oxytocin infusion should be monitored against uterine contractions and

increased every half-hour until contractions are 3 or 4 in 10 minutes, each lasting 20
– 40 seconds.
 Stop oxytocin if there is uterine hyperactivity and/or foetal distress
 Turn woman on the left side
 Ensure adequate hydration

6.0 CONCLUSION

1. A Partograph remains an important tool for health workers in Uganda for managing
women in labour. It helps midwives and doctors to know early enough when something is
going wrong with the mother or baby, so that appropriate action is taken.
2. All mothers in labour should be monitored using a Partograph.
3. All health units should ensure that midwives and doctors working in the labour ward know
how to use and interpret the partograph.
4. Appropriate action should always accompany use and interpretation of the Partograph.

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ANNEX I: CASE STUDY

Mrs. Otim Mary aged 22 years, Gravida 3, Para 2, was admitted in Ngora Hospital Maternity
on 11/8/2005 at 10.00 a.m. IP No. 360/2005. Her LNMP was 4/11/2004, EDD ……… WOA.
On admission, the general condition was good, Temp 36 0C, pulse 74, BP 100/60 . Passed urine
200 mls but not tested, foetal heart – 130bpm. Contractions 3:10 lasting 20-40 seconds. 5/5 of
the head was palpable V/E – cervix 4 cm dilated. Membranes were intact, no moulding –
150mls of tea were given.

At 2pm – FHR was 138bpm, descent was 2/5, BP – 100/60, she passed ….. urine, contractions
were 4:10 lasting 45 seconds. Cervical dilatation was 8 cm dilated, membranes were ruptured
spontaneously, drained clear liquour , no moulding 4:10 lasting 45 seconds. At 3 pm mother
felt like bearing down. Cervix was 10 cm dilated. Head not palpable above the rim.

TASK:
i) Plot this information on partograph
ii) How long did she take in the 1st stage?

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