Uses of Partograph

morbidity took place among both nulliparous and multiparous women after the use of a partograph
19

The partograph has been in use since 1970 in a number of countries, and used extensively in many centres , , , , , , , , , , , . It has been found to be inexpensive, effective and pragmatic in a variety of different settings including developed and developing counties. It has shown to be effective in preventing prolonged labour, in reducing operative intervention and in improving the neonatal outcome , , , , , . Prolonged sections reduced , labour, and
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augmented

labor,

caesarean were

intrapartum

fetal

deaths

The use of a partogram for the management of labour has been shown to be beneficial in that it clearly differentiates normal from abnormal progress in labor and identifies women likely to require intervention.

Active

management

of

labor

advocates

early

recognition of non-progressive labor. This can be done by using a partograph, or graphical depiction of a labor curve. The first stage of labor has two phases, a latent phase and an active phase. In

The Partograph primigravidae, the latent phase is often long (about 8 The partograph, a sigmoid curve, is a tool that can be used to assess the progress of labor and to identify when intervention is necessary. It is a graphical record of cervical dilatation in centimeters against duration of labor in hours. Studies have shown that using the partograph can be highly effective in reducing complications from prolonged labor for the mother (postpartum hemorrhage, sepsis, uterine rupture, etc.) and for the newborn (death, anoxia, infections, etc.). In a WHO multicentre trial hours) during which effacement occurs. In

multigravidae, the latent phase is short (about 4 hours) and effacement and dilatation occur

simultaneously. Dilatation of the cervix at the rate of 1 cm per hour in primigravidae and 1.5 cm in multigravidae beyond 3 cm dilatation is considered satisfactory. The alert line drawn from 3 cm to 10 cm in active stage represents the rate of dilatation. Therefore, if cervical dilatation moves to the right of the alert line, it is slow and indication of delay in labour. If the woman is in a health centre, she should

improvements in maternal and fetal mortality and

be transferred to hospital: if in hospital, she should be observed more frequently.

contractions. It will also be used for monitoring fetal conditions with the following parameters: fetal heart rate, membranes and liquor and moulding of fetal

A partograph must be started only when a women is in labor. In the latent phase (cervix dilatation not more than 2 cm), she should have one contraction in 10 minutes, each lasting 20 seconds or more. In the active phase (cervix dilatation more than 3 cm), she should have two or more contractions in 10 minutes, each lasting 20 seconds or more.

skull. Additionally, the partograph can be used to monitor maternal condition: pulse, blood pressure, temperature, urine, drugs, IV fluids, and oxytocin.

Labour is monitored by observing the progressive effacement and dilatation of the cervix and the descent of the presenting part against time in a chronological manner. The frequency and duration of

E.A Friedman in 1954 first described a normal cervical dilatation pattern

20

uterine contractions is also noted. The maternal condition is monitored by observing the pulse, blood pressure, temperature and hydration. In addition, the use of anesthetic and oxytocic drugs can be recorded in the partogram. The fetus is monitored closely on the partograph by regular observation of the fetal heart rate, the liquor, and the moulding of the fetal skull bones. A gradual increase in the basal FHR or prolonged bradycardia indicates the possibility of fetal distress. The colour of the amniotic fluid if heavily stained with meconium (thick or grade 3), with scanty fluid or fresh passage of meconium, or the absence of amniotic fluid at the time of the rupture of membranes is suggestive of possible hypoxia.

. Various authors have

developed similar nomograms in many geographical areas. None of these have shown significant

differences between ethnic groups , , , , , , , . This can be used at all levels of obstetric care by basic care providers who are trained to assess cervical dilatation. When used properly, it helps to detect cases of abnormal labour without delay, thus allowing timely intervention.

5 7 21 22 23 24 25 26

The WHO model of the partograph represents in some ways a synthesized and simplified compromise, which includes the best features of several

partographs , , , , , , , , , , . The fetal condition, the progress of labour and the maternal condition are the three components of the partogram.

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Conclusion

The partograph is used to assess the progress of The partograph is used to plot the following parameters for the progress of labor: cervical dilatation, descent of fetal head, and uterine labor and to identify when intervention is necessary. Studies have shown that using the partograph can be

highly effective

in

reducing

complications

from

prolonged labor for the mother and for the newborn. Prolonged labour, augmented labor, caesarean

sections/ operative interventions, neonatal morbidity and intrapartum fetal deaths were reduced with the use of the partograph. Easy and early recognition of poor progress of labour (with the use of partograph) and the prevention of prolonged labour significantly reduce the risk of postpartum haemorrhage and sepsis, and eliminate obstructed labour, uterine rupture and thereby reduce the maternal mortality

How to use it? A partograph must be started only when a women is in labor.In the latent phase (cervix dilatation not more than 2 cm), she should have two or more contractions in 10 minutes, each lasting 20 seconds or more. In the active phase (cervix dilatation more than 3 cm), she should have one or more contractions in 10 minutes, each lasting 20 seconds or more. The partograph is used to plot the following parameters for theprogress of labor: cervical dilatation, descent of fetal head, and uterine contractions. It will also be used for monitoring fetal conditions with the following parameters: fetal heart rate, membranes and liquor and moulding of fetal skull. Additionally, the partograph can be used to monitor maternal condition: pulse, blood pressure, temperature, urine, drugs, IV fluids, and oxytocin. In this site, we will only explain how to use the partograph for monitoring labor (cervical dilatation and descent of fetal head). For additional information, please refer to: Preventing Prolonged labor: A Practical Guide. The Partograph, WHO/FHE/MSM/93.8.

References

1. World Health Organization. Preventing Prolonged labor: A Practical Guide. The Partograph. Maternal Health and Safe Motherhood Programme, Geneva, 1993 , WHO document WHO/FHE/MSM/93.8. (s) Partograph What is it? The Partograph is a tool that can be used by midwifery personnel to assess the progress of labor and to identify when intervention is necessary. Studies have shown that using 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.). Who uses it? Nurse midwife, medical doctor, nurse. Why use it? To assist in making the correct decision about transfer, Caesarean section, or other life-saving interventions. When to use it? To monitor all stages of labor of all women arriving at the maternity or health facility. 1. Cervical dilatation: The rate of dilatation of the cervix changes during labor, this is represented by the bold lines in the graph. Dilatation of the cervix is measured by the diameter in cm. This is recorded with an X in the center of the partograph, at the intersection of vertical and

horizontal lines. The vertical scale represents dilatation by 10 squares of 1 cm each. The horizontal scale represents time by 24 squares of one hour each. When labor goes from latent to active phase, the dilatation must be plotted on the alert line. The latent phase should normally not take longer than 8 hours. When admission takes place in the active phase, the dilatation is immediately plotted on the alert line. If progress is satisfactory, the plotting of the cervical dilatation will remain on or to the left of the alert line (see graph). 2. Descent of fetal head: Descent of the fetal head may not take place until the cervix has reached about 7 cm of dilatation. This is measured by abdominal palpation and expressed in number of finger widths (fifths of the head) above the pelvic brim. It is also recorded in the central part of the partograph with an "O". Example: Using pediatric growth charts and growth percentile calculators Pediatric growth charts are simple grids that allow you to plot a child's height, according to his or her age. On this page, you'll learn how to read growth charts. Then, you'll have the opportunity to enter a child's age and heightto find out how the child's height compares with sample heights of other children the same age. A child's height and weight are often measured and Admission time was 13:00, the dilatation of the cervix was 1 cm and the head was 5/5 above the pelvic brim. At 17:00, the dilatation was 5 cm (active phase), and the head was 4/5 above the brim. Labor is now in active phase. Cervical dilatation is immediately transferred to the alert line; descent of the head and time are transferred to the vertical line intersecting the 5 cm line on the alert line. At 20:00, the cervix was fully dilated (10 cm), and the head was only 1/5 above the pelvic brim. The total length of the first stage of labor observed in the unit was 7 hours. marked on his or her growth chart as part of every visit to a healthcare provider. Children under age 3 are usually measured at least every 6 months; children over 3, every year. If there is any concern about growth, measurements may be made as often as every 3 months until a growth pattern becomes clear. Percentiles The most widely used growth charts are constructed by measuring many boys and girls of all

ages and breaking the range of their heights and weights into percentiles. These percentiles represented on are the

growth charts below by the colored bands. Age in years is marked along the bottom of the chart. Height in inches is marked along the left side. The 50th percentile is the average height for any given age. on the growth chart). Using a pediatric growth chart A pediatric growth chart shows us how a child's height compares with those of other children the same age. It also shows us a child's growth pattern over time. After 2 years of age, most children maintain steady growth throughout childhood, along one of the percentile lines. Children over 2 years of age who move away from their established growth To use the chart, find the child's age along the bottom and draw a straight line going up, parallel to the right and left sides of the chart. Then find the child's height along the side and draw a line across, marking the point where the child's age line and height line cross. By looking at the boys' growth chart above, for example, we can tell that a 10-year-old boy who is 55 inches tall is average size (50th percentile) for his age (point A on the growth chart). A 10-year-old boy who is only 50 inches tall, however, falls at about the 5th percentile (point B curve should be thoroughly evaluated by a healthcare provider, no matter how tall they are. Now let's look at the girls' growth chart, which shows two girls' growth patterns represented by curved dotted lines. The child whose growth is shown on curve A is more likely to have a growth problem than the child whose growth is shown on curve B. The reason is that although child B is shorter, she's continuing to grow as expectedin this case, along the 10th percentile. While child A is still taller than 50%

to 75% of children her age, the growth chart shows that her rate of growth has slowed over the past 2 years (see dashed lines in graph above). She needs to see her healthcare provider promptly so the cause of her growth failure can be investigated. Using a growth percentile calculator

Use the growth percentile calculator below to enter a child's sex, age, and height and see the child's

practices The Partograph: An Essential Tool for Decision-Making during Labor The partograph is a vital tool for providers who need to be able to identify complications in childbirth in a timely manner and refer women to an appropriate facility for treatment. Prolonged labor is a leading cause of death among mothers and newborns in the developing world. It is most likely to occur if a womans pelvis is not large enough for her babys head to pass through or if a womans uterus does not contract sufficiently. If her labor does not progress normally, the woman may experience serious complications such as obstructed labor, dehydration, exhaustion, or rupture of the uterus. Prolonged labor may also contribute to maternal infection or hemorrhage and to neonatal infection. Skilled management of labor using a partograph, a simple chart for recording information about the progress of labor and the condition of a woman and her baby during labor, is key to the appropriate prevention and treatment of prolonged labor and its complications. Following the recommendation of the World Health Organization (WHO), the Maternal and Neonatal Health (MNH) Program promotes the use of the partograph to improve the management of labor and to support decision-making regarding interventions. When used appropriately, the partograph helps providers identify prolonged labor and know when to take appropriate actions. History of the WHO Partograph The normal pattern of labor, including two phases (latent and active) of cervical dilation, was first documented on a graph in the 1950s. In the 1960s and 1970s, further research helped to chart the progression of labor and to build a scientific basis for interventions to prevent prolonged labor. These early partographs formed the foundation for the WHO model of the partograph, which was

developed as an international standard in 1988 following the launch of the worldwide Safe Motherhood Initiative. In 19901991, to evaluate the impact of the new partograph, WHO conducted a multicenter trial involving more than 35,000 women in Indonesia, Malaysia, and Thailand. The study showed that when the partograph was introduced into clinical practice along with a management protocol, labor outcomes were greatly improved. Use of the partograph reduced the number of prolonged labors (those longer than 18 hours), the need for augmentation of labor with oxytocin, rates of cesarean section, and the incidence of infection. As a result of this study, WHO recommended that the partograph be used in monitoring all labors to help identify abnormal progress and women who might need further interventions. How the Partograph Works The partograph is a printed graph representing the stages of labor. Once a woman is in active labor, the skilled provider regularly plots the descent of the baby as well as the dilation of the womans cervix to help keep track of