CHAPTER I

INTRODUCTION

I. Background 1,2
Globally, there were an estimated number of 287.000 maternal deaths in 2010. This
means, every day, approximately 800 women die from preventable causes related to
pregnancy and childbirth. The largest numbers and highest rates of maternal, neonatal
and child deaths are in countries of sub-Saharan Africa and South Asia. A total of 10
countries have almost two thirds the global burden of maternal and newborn deaths, as
well as stillbirths. Our knowledge of major causes of maternal and newborn has increased
in parallel with improved global statistic on mortality burden and trend and improved
methods for allocating cause of death, although methods and estimates vary considerably.
Labor and delivery are unpredictable events, which if not monitored properly can
result in a disable or a fatal state. The World Health Organization (WHO) promotes use
of the partograph to monitor and improve the management of labor and to support
decision-making regarding interventions. Several interventions have been designed to
curb this alarming high rate of maternal mortality rate. Among these interventions, skilled
attendance during pregnancy, labor and delivery have been identified as the most
important factor in the short term reduction of maternal mortality and morbidity in the
country.
II. Aim to Study
1. To explain about obstetric physical examination.
2. To explain about how to use partograph.
III. Benefits
As a reference and give information about obstetric physical examination and
how to use partograph.

CHAPTER II

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 LITERATURE REVIEW

I. OBSTETRIC PHYSICAL EXAMINATION

1. ESTIMATED DATE OF CONFINEMENT3

After a positive diagnosis, the duration of pregnancy and the estimated date of
confinement (EDC) must be determined. Because it is uncommon to know the exact onset
of pregnancy, these calculations start from the first day of the last menstrual period
(LMP). A patient with a regular 40-day cycle obviously will not ovulate on day 14 but
closer to or on day 26. Therefore, her EDC cannot be estimated accurately by Nageles
rule alone. Primiparas tend to have slightly longer gestations than multiparas.

NAGELES RULE

Add 7 days to the first day of the LMP, subtract 3 months, and add 1 year.

EDC = (LMP + 7 days) - 3 months + 1 year

For example, if the first day of the LMP was June 4, the EDC will be March 11 of the
following year.

Nageles rule is based on a 28-day menstrual cycle with ovulation occurring on

the 14th day. In calculating the EDC, an adjustment should be made if the patients cycle
is shorter of longer than 28 days. The discrepancies caused by 31-day months and the 29-
day variation in February of leap year are not correctable by Nageles rule. Nevertheless,
it provides an acceptable estimate of the EDC.

2. UTERINE SIZE 3

The fundal height is measured with a tape from the top of the symphysis pubis,
over the uterine curve, to the top of the fundus. This technique places an emphasis on
change in growth patterns rather than the absolute measurement in centimeters, which
can vary between patients. In women who are obese, periodic ultrasound assessments of
fetal growth may be necessary. Gestational age is approximately equal to fundal height in
centimeters from 16 to 36 weeks gestation. Measurements that are more than 2 cm smaller

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 than expected for week of gestation are suspicious for oligohydramnios, IUGR, fetal
anomaly, abnormal fetal lie, or premature fetal descent into the pelvis. Conversely, larger
than expected measurements may indicate multiple gestation, polyhydramnios, fetal
macrosomia, or leiomyomata. These concerns can be resolved with ultrasound
examination4

Table 1. Uterine Height and Stage of Gestation 3

Week of Pregnancy Approximate Height of Fundus

12 Just palpable above symphysis
15 Midpoint between umbilicus and symphysis
20 At the umbilicus
28 6 cm above the umbilicus
32 6 cm below the xiphoid
36 2 cm below the xiphoid
40 4 cm below the xiphoid

Figure 1 The height of the fundus at comparable gestational dates varies among patients.4

3. FETAL WEIGHT3

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 Most examinations involve an estimate of the height of the fundus uteri on the
abdomen, not the length of the uterus. A more precise estimation can be made by the
modified McDonalds rule.

MODIFIED MCDONALDS RULE

Measure the height of the fundus (over the curve) above the symphysis with a
centimeter tape measure. The distance in centimeters will approximate the gestational
age from 1638 weeks 3 weeks.

The same examiner should measure the fundus whenever possible because
variations by personnel may inaccurately suggest pregnancy complications. Additionally,
a rough guide to fetal weight may be calculated from the modified McDonalds uterine
measurement (Johnsonsrule). However, recall that wide variations in the weights of
fetuses in the third trimester may be due to the following.

The age-weight patterns of previous infants

An expected increase in weight of each successive infant
Hereditary traits or acquired disorders affecting infant size, for example, race,
nutrition, diabetes mellitus, preeclampsia-eclampsia.

JOHNSONS ESTIMATE OF FETAL WEIGHT

Fetal weight (in grams) is equal to the fundal measurements (in centimeters)
minus n, which is 12 if the vertex is at or above the ischial spines or 11 if the vertex is
below the spines, multipliedby 155.

Example: A gravida with a fundal height of 30 cm whose vertex is at -2 station

can be represented as (30 - 12) x 155 = 2790 g. If the patient weighs >200 pounds, subtract
1 cm from the fundal measurement. By this calculation, an estimate within 375 g can be
expected for about 70% of neonates.

Fetal weight should be estimated by carefully palpating the gravid uterus and
mentally adjusting for amniotic fluid volume, thickness of the maternal abdomen, and the
proportion of the fetus engaged in the pelvis.

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 Fundal size larger than expected by the gestational age suggests incorrect dates,
fetal or maternal anomalies (including macrosomia), or multiple gestation.

o None of these possibilities can be resolved with assurance by palpation; an immediate

ultrasound exam is required.

o Sonographically estimated fetal weight performed at term has a margin of error of up

to 500 g.

4. FETAL HEART RATE 5

Auscultate the fetal heart, noting its rate (FHR), location, and rhythm. Use either:

A doptone, with which the FHR is audible after 12 weeks, or

A fetoscope, with which it is audible after 18 weeks.

The rate is usually in the 160s during early pregnancy, and then slows to the 120s to 140s
near term. After 32 to 34 weeks, the FHR should increase with fetal movement.

The location of the audible FHR is in the midline of the lower abdomen from 12
to 18 weeks of gestation. After 28 weeks, the fetal heart is heard best over the fetal back
or chest. The location of the FHR then depends on how the fetus is positioned. Palpating
the fetal head and back helps you identify where to listen. If the fetus is head down with
the back on the womans left side, the FHR is heard best in the lower left quadrant. If the
fetal head is under the xiphoid process (breech presentation) with the back on the right,
the FHR is heard in the upper right quadrant.

Lack of an audible fetal heart may indicate pregnancy of fewer weeks than
expected, fetal demise, or false pregnancy. An FHR that drops noticeably near term with
fetal movement could indicate poor placental circulation.

After 24 weeks, auscultation of more than one FHR with varying rates in different
locations suggests more than one fetus.

5. FETAL HEART TONES 5,6

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 Documentation of the fetal heart tones must be performed on admission.

Continuous electronic fetal heart rate monitoring (CEFM) is performed as an initial

evaluation at many institutions. The baseline heart rate, variability, accelerations, and
decelerations are carefully assessed.

If a reassuring tracing is obtained, the patient may continue to be managed with

CEFM, or may be a candidate for intermittent fetal heart rate monitoring by
auscultation.

The analysis of these characteristics is then interpreted as a reassuring or non

reassuring assessment of fetal acid base and oxygenation status.

Fetal heart rate baseline

The National Institute for Child Health and Human Development defines
baseline fetal heart rate as the approximated mean fetal heart rate, rounded to
increments of 5 bpm during a 10-min window, excluding periodic or episodic
changes, periods of marked fetal heart rate variability, or segments of the baseline
that differ by greater than 25 bpm.

Fetal heart rate reactivity

Fetal heart rate reactivity is two or more accelerations in a 20-minute

period . The presence of accelerations and reactivity is reassuring of an intact and
functioning fetal central nervous system.

Variability

Baseline variability is defined as fluctuations from baseline fetal heart rate

of two cycles or more per minute. Beat-to-beat variability is the small,
instantaneous differences in the RR interval:

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 Literally, it is the difference in the FHR baseline from one beat to the next
beat.
Beat-to-beat variability can only be measured accurately by internal
monitoring systems.

Long-term variability refers to state changes induced by alternating

periods of fetal sleep and activity. Gradations of variability include undetectable,
minimal, moderate, marked, and sinusoidal.

Accelerations

Accelerations are elevations of fetal heart rate at least 15 bpm above

baseline, lasting at least 15 seconds. Accelerations are typically abrupt in onset
and are associated with fetal movements. Anything that suppresses central
nervous system activity (sleep, drugs, acidosis, etc.) can also suppress
accelerations and reactivity.

Figure 2. FHR Accelerations

Decelerations

o Early decelerations
Early decelerations are secondary to fetal head compression and are
benign.
They are uniformly shaped decelerations of minimal amplitude, have a
slow onset, slow return to baseline, and are in phase with the uterine
contraction cycle.
The deceleration begins early in the contraction cycle, drops to its lowest
point with the peak of the contraction force, and returns to baseline before
the contraction ceases.

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 The amplitude of the deceleration roughly parallels the strength of the
contraction but rarely exceeds 30 bpm below the baseline.

Figure 3. FHR Decelerations

o Variable decelerations
Variable decelerations are V-shaped decelerations associated with
umbilical cord compression and reduction in blood flow through the
umbilical vein.
Variable decelerations have an abrupt onset and quick return to baseline.
The duration, intensity, and timing of each variable deceleration relative to
its contraction may differ markedly.

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 Variable decelerations are graded as mild, moderate, or severe, depending
on the amount of associated cord compression and hypoxia.
Mild variable decelerations last less than 30 seconds or do not drop
below 80 bpm regardless of duration.
Moderate decelerations reach a heart rate of 70 to 80 bpm
regardless of duration.
Severe variable decelerations reach fetal heart rates <70 bpm for
more than 60 seconds.

o Late decelerations
Late decelerations are named for the timing of their onset and cessation.
The decrease in fetal heart rate occurs after the start of a uterine
contraction, and the return to baseline is delayed until after the end of the
contraction.
The onset of a late deceleration occurs up to 30 seconds after the start of a
contraction, and its nadir occurs well after peak contraction strength has
been reached.
The decreased fetal heart rate continues after the contraction has ended,
with return to baseline delayed for up to 30 seconds.
Reassuring and non reassuring fetal heart rate patterns

o To differentiate reassuring from non reassuring patterns, first identify

Baseline fetal heart rate

Presence of accelerations or decelerations

Frequency, type, and severity of decelerations

Presence or absence of variability.

o A reassuring fetal heart rate pattern consists of

Baseline fetal heart rate between 120 and 160 bpm

Moderate variability

The presence of accelerations

The absence of significant decelerations.

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 o A non reassuring pattern involves the absence of reassuring features.
Non reassuring patterns identify fetuses at risk for intrauterine
compromise.
When a non reassuring pattern is identified, further evaluation or treatment
of the fetal condition is indicated.
Uncommon patterns of fetal heart rate (Fig. 32-7) include:

o Prolonged decelerations (isolated decelerations longer than 60 to 90 seconds)

o Saltatory patterns (characterized by frequent high-amplitude accelerations
(>25 bpm)
o Sinusoidal patterns (normal baseline with smooth, regular sine-wave
oscillations above and below the baseline occurring 2 to 5 times a minute and
not exceeding 15 beats in amplitude)
o Bradyarrhythmias (slow fetal heart rate baseline below 90 bpm)
o Tachyarrhythmias (sustained fetal heart rate in excess of 200 bpm).

6. LEOPOLD MANUEVERS4,6

It is essential to determine the position of the fetus within the uterus for labor
management. This may be accomplished with the four maneuvers described by Leopold
for examination of the abdomen. 6

These are initiated at midpregnancy, when fetal body parts are more clearly
identified. The maneuvers consist of four parts; the first three are performed with the
examiner standing to one side of the patient and facing her head and the last with the
examiner facing the patient's feet. 4

1. The first maneuver determines which fetal pole occupies the uterine fundus (e.g., the
breech with a vertex presentation). The breech moves with the fetal body. The vertex
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 is rounder and harder and feels more globular than the breech and can be maneuvered
separately from the fetal body.6

Figure 4. Leopold I

2. With the second maneuver, the lateral aspects of the uterus are palpated to determine
on which side the fetal back or fetal extremities, or small parts are located. The small
parts are less firm than the back, and often movement is apparent. The palms of the
hands are placed on either side of the abdomen. On one side, the linear continuous
ridge of the back is felt; on the other side, compressible areas and nodular parts are
found. 4,6

Figure 5 Leopold II

3. The third maneuver reveals what fetal part lies over the pelvic inlet. A single
examining hand is placed just above the symphysis. The fetal part that overrides the
symphysis is grasped between the thumb and third finger. If the head is unengaged, it
is readily recognized as a round, hard object that frequently can be displaced upward.
After engagement, the back of the head or a shoulder is felt as a relatively fixed,
knoblike part. In breech presentations, the irregular, nodular breech is felt in direct
continuity with the fetal back. 4,6

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 Figure 6. Leopold III

4. The fourth maneuver reveals the presentation. This maneuver can be performed only
when the head is engaged; if the head is floating, the maneuver is inapplicable. The
examiner faces the patient's feet and places a hand on either side of the uterus, just
above the pelvic inlet. When pressure is exerted in the direction of the inlet, one hand
can descend farther than the other. With the fetus presenting by vertex, the cephalic
prominence may be palpable on the side of the fetal small parts, confirming flexion of
the fetal head (occiput presentation). Extension of the head (face presentation) is
suspected when the cephalic prominence is on the side of the fetus opposite the small
parts.4,6

Figure 7. Leopold IV

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Figure 8. Descent of the fetal head measured by abdominal palpation and expressed in
terms of fifths above the pelvic brim.

PRESENTATION 6

Presentation describes that part of the fetus that is lowest in the pelvis is the
vertex, the breech, or the shoulder.

o Vertex presentation is most common.

o Brow or face presentation is a variation on vertex, but with deflexion of the fetal
head, allowing the brow or face to enter the pelvis first.

o In a breech presentation, the fetal buttocks (the breech) are the presenting part.
The breech presentation has several variations:

Frank breech: the fetal legs are extended above the fetal pelvis with the
breech as the presenting part

Complete breech: the feet and buttocks present together

Single-footling breech: one leg/foot is extended and presenting

Double-footling breech: both legs/feet are extended and presenting.

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 o Although all abnormal presentations have an increased incidence of cord prolapse,
footling breeches are especially at risk.

o A shoulder presentation implies a transverse lie.

o Compound presentations (e.g., vertex and an extremity together) rarely are seen
with term pregnancies.

o The position of the presenting part is best determined by vaginal examination.

7. PELVIC EXAMINATION
Inspection and palpation of the perineum and the pelvis are critically important in
evaluating the laboring patient. Information elicited includes:

o Presence or absence of perineal, vaginal, and cervical lesions (including herpes or

human papilloma virus infections)

o Adequacy of the bony pelvis

o Integrity of the fetal membranes

o Degree of cervical dilation and effacement

o Station of the presenting part.

The presence of third-trimester vaginal bleeding or preterm premature rupture of

the membranes will preclude digital examination of the cervix until further evaluation
is performed.
a. Inspection

The perineum should be inspected for herpetic lesions, large vulvar varicosities,
large condylomas, and evidence of poorly healed perineal lacerations. If there is any
question of active genital herpes and examination of the vagina or cervix is necessary,
this should be done with a speculum rather than digitally. Cyanosis of the vagina
(Chadwicks sign, Jacquemiers sign) is present by about 6 weeks. 1 Diagnosis of

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ruptured membranes may sometimes be visually confirmed by inspection, but it is
often necessary to perform a sterile speculum examination to determine the status of
the fetal membranes.

o Using sterile technique, a sterile speculum is inserted into the vagina, and a light
source is positioned so the cervix and posterior vagina can be visualized.

o Gross pooling of amniotic fluid in the posterior fornix is almost 100% diagnostic
of ROM.

o Direct transcervical visualization of fetal scalp, feet, umbilical cord, or other fetal
parts confirms ruptured membranes.

o If uncertain about ROM, any fluid pooled in the posterior vaginal fornix is
sampled with a sterile cotton swab, smeared on a glass slide, and applied to
nitrazine paper.

Ferning of the air-dried fluid under the microscope suggests amniotic fluid. The
alkaline pH of amniotic fluid causes nitrazine paper to turn deep blue, indicating a
positive result. Blood and sometimes urine may cause false-positive results.

Figure 9. Typical ferning pattern of dried amniotic fluid

o If bloody amniotic fluid is noted (port-wine fluid), further investigation to rule out
abruptio placentae should be undertaken.

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o The absence or presence of meconium (fetal stool) in the amniotic fluid should be
noted.

The incidence of meconium-stained amniotic fluid increases with

advancing gestational age.

Although it may be released into the amniotic fluid during hypoxic stress,
this is not pathognomonic for hypoxemia.

o Absence of amniotic fluid noted at the time of attempted amniotomy should be

considered as evidence for the presence of thick meconium until proven otherwise.

Cultures are obtained when preterm labor or chorioamnionitis is suspected.

With preterm ROM, a sample of amniotic fluid from the vaginal pool can be
be obtained to evaluate fetal lung maturity.

b. Palpation of the Cervix 3,6

Softening of the tip of the cervix (Fig. 5-1) occasionally is noted by the
4th5th week of pregnancy. However, infection or scarring may prevent softening
until late pregnancy.

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 Figure 10. Softening of the tip of the cervix

Softening of the cervicouterine junction often occurs by 56 weeks. A soft

spot may be noted anteriorly in the middle of the uterus near its junction with the
cervix (Ladins sign).

Figure 11. Ladins sign

A wider zone of softness and compressibility in the lower uterine segment

(Hegars sign) is the most valuable sign of early pregnancy and can usually be
noted at 6 weeks. Ease in flexing the fundus on the cervix (McDonald s sign)
generally appears by 78 weeks.

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 Figure 12. Hegars sign

Irregular softening and slight enlargement of the fundus at the site of or

on the side of implantation (Von Fernwald s sign) occur by 5 weeks. Similarly,
if implantation is in the region of a uterine cornu, a more pronounced softening
and suggestive tumor like enlargement may occur (Piskaceks sign).

Figure 13. Piskaceks sign

Generalized enlargement and diffuse softening of the uterine corpus usually

occur 8 weeks of pregnancy.

Palpation of the cervix should be done when the patient is between

contractions to ensure accuracy and to minimize the patient's discomfort.

Dilation of the cervix describes the degree of opening of the cervical os. The
cervix can be described as undilated or closed (0 cm), fully dilated (10 cm), or
any point between these two extremes (0 to 10 cm).

Effacement of the cervix describes the process of thinning that the cervix
undergoes before or during labor.

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o The thick prelabor cervix is approximately 3 cm long and is said to be uneffaced
or to have 0% effacement. With complete or 100% effacement, the cervix is paper
thin.

As a general rule, primiparous women begin to efface the cervix before

dilation begins, whereas multiparous women begin to dilate before significant
effacement has been reached.

Figure 14. Degree of cervical effacement.

A: No effacement. B: 75% effacement. C: 100% effacement.

Identification of fetal presentation should be confirmed by digitally palpating

the fetal presenting part. The novice often assumes it to be a vertex, but
identification must be positively made on every occasion.

o Vertex presentation can be confirmed by palpating the suture lines of the fetal
skull. If the suture lines cannot be identified with certainty, other presentations
must be considered.

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o Palpation of the fetal buttocks, feet, face, or arms is confirmatory.

o Inability to positively identify the presenting part demands an ultrasound

examination.

Station refers to the relationship between the fetal presenting part and pelvic
landmarks.

o Hodge field identify the lowest part of the fetus down in the pelvis :

Hodge field I : a plane through the top of the symphisis and promontory.
Hodge field II: a field parallel to the hodge field I as high as the bottom of the
symphisis
Hodge field III: a field parallel to the hodge field I and II as high as to the
right and left ischial spines. On the other references its called O field.
Hodge field IV: a field parallel to the hodge field I, II, and III, as high as to
the coccyx.

Figure 15. Hodge Field

o When the presenting part is at zero station, it is at the level of the ischial spines,
which are the landmarks for the midpelvis. This is important in the vertex
presentation because it implies that the largest dimension of the fetal head, the
biparietal diameter, has passed through the smallest dimension of the pelvis, the
pelvic inlet.

o In 1988, the American College of Obstetricians and Gynecologist introduced a

classification dividing the pelvis into 5-cm segments above and below the spines:

If the presenting part is 1 cm above the spines, it is described as -1 station.

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 If it is 2 cm below the spines, the station is +2.

At -5 station, the presenting part is described as floating.

At +5 station, the presenting part is on the perineum, and it may distend

the vulva with a contraction and be visible to an observer.

Figure 16. Estimation of descent of fetal head into the pelvis. Zero station is
diagnosed when the fetal vertex has reached the level of the ischial spines.

Position of the presenting part is described as the relationship between a certain

landmark on the fetal presenting part and the maternal pelvis, as follows:

Anterior, closest to the symphysis

Posterior, closest to the coccyx

Transverse, closest to the left or right vaginal sidewall.

The index landmark in a vertex presentation is the occiput, which is

identified by palpating the lambdoid sutures forming a Y with the sagittal suture;
it is the sacrum in a breech presentation, and the mentum (or chin) in a face
presentation.

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 The designations of anterior, posterior, left, and right refer to the maternal
pelvis. Therefore, right occiput transverse implies the occiput is directed toward
the right side of the maternal pelvis.

Breech and face presentations are described in a similar fashion (e.g., right
sacrum transverse, right mentum transverse).

c. Evaluation of Pelvic Adequacy 4,6

The shape of the maternal pelvis may be visualized as a cylinder with a gentle
anterior curve toward the outlet. The curve forms because the posterior border
of the pelvis (the sacrum and the coccyx) is longer than the anterior border
(the symphysis pubis). The lateral borders (the innominate bones) are more or
less parallel in the normal female pelvis.

Dystocia may be encountered when abnormalities of the pelvis are present.

Pelvic adequacy can be judged clinically by measuring pelvic diameters at
certain levels.

Even when conducted by the most experienced clinicians, clinical pelvic

measurements are merely estimations.

o Unless the maternal pelvis is grossly contracted, adequacy is proved only by a

trial of labor.

o Despite this, the pelvis must be evaluated at admission for an estimate of

adequacy or documentation of abnormalities.

The maternal pelvis is one of three factors that determine the success of labor.
These factors have been referred to as the three P's: pelvis, power, and
passenger. A macrosomic fetus or inadequate uterine contractions, even with
an adequate pelvis, may preclude vaginal delivery.

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 Figure 17. Various vertex presentations and vaginal palpation of the large and small
fontanelles and the frontal, sagittal, and lambdoidal sutures determines the position of
the vertex. LOP, left occiput posterior; LOT, left occiput transverse; LOA, left
occiput anterior; ROP, right occiput posterior; ROT, right occiput transverse; ROA,
right occiput anterior.

Inlet

The inlet of the true pelvis is limited by the symphysis pubis anteriorly, the sacral
promontory posteriorly, and the iliopectineal line laterally.

The anteroposterior (AP) diameter of the inlet may be estimated by determining the
diagonal conjugate measurement. The diameter (the distance from the sacral
promontory to the inner inferior surface of the symphysis pubis) is measured
clinically by attempting to touch the sacral promontory with the vaginal examining
finger while simultaneously noting where the inferior border of the symphysis
touches the examining finger (Fig. 2-7). A measurement >12 cm suggests adequacy.

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 Figure 18. Estimation of diagonal conjugate measurement. Fingers inserted in the
vagina reach for the promontory of the sacrum, and the point at which the symphysis
pubis touches the metacarpal bone is noted (left). The distance is measured with the
calipers (right).

Midpelvis

The midpelvis is bordered anteriorly by the symphysis pubis, posteriorly by the

sacrum, and laterally by the ischial spines. A gently curved concave sacrum increases
the adequacy of the midpelvis.

The interspinous diameter is estimated by palpating the ischial spines. An estimated

distance >9 cm suggests midpelvis contraction. Experience is required to estimate this
diameter with accuracy.

Figure 19. Palpation of ischial spines to estimate interspinous diameter.

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 Outlet

The outlet is limited anteriorly by the arch of the symphysis pubis, posteriorly by the
tip of the coccyx, and laterally by the ischial tuberosities.

This transverse diameter of the outlet can be estimated by placing a clenched fist
between the two ischial tuberosities. A measurement of 8 cm or more suggests an
adequate diameter.

The AP measurement is estimated by judging the prominence of the tip of the sacrum
and by noting the angle made by the pubic rami. A narrow pelvic arch decreases the
effective AP diameter.

Dystocia as a result of an abnormal outlet alone is unusual, although with midpelvic

inadequacy, the outlet is also usually inadequate.

II. PARTOGRAPH 7

Partograph is use to record partograph observations and progress of labor and

birth process to know whether the process runs normally. World Health Organization
(WHO) 2002 had modified partograph to be more simple and easy use. Recording of the
partograh beginning of the active phase when the opening of the cervix.

Observation starts from the active phase, and there are rows and column to write down
the result on every examination during active phase, include:

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1. Information about the maternal:
2. Time of rupture of the membranes
3. Fetal Condition
4. Progress of Labor
5. Time
6. Uteric Contraction
7. Medication
8. Maternal Condition

1. INFORMATION ABOUT THE MATERNAL 7

- Name, age
- Gravid, Para, Abortus
- Medical record
- Date and time
2. FETAL CONDITION7
a. Fetal Heart Rate (FHR)

The fetal heart rate may be assessed intermittently every 30 minutes (more often if
there is sign of emergency). The baseline rate should be between 110-160 beats per
minute (bpm). Every box of this, show 30 minutes. The number scale on the left
column show the FHR. Note the FHR with a point on the row based on the number of
FHR. Then connect one point to the other point with a solid line.

b. Liquor (Amniotic fluid)

Value the amniotic fluid every vaginal toucher and value the color if the
membranes rupture. Write down the result below the FHR row. Use this sign :

U : if the membranes still intact

J : if the membranes rupture and the amniotic fluid is clear.
M : if the membranes rupture and the amniotic fluid mix with meconium
D : if the membranes rupture and the amniotic fluid mix with blood
K : if the membranes rupture and no amniotic fluid

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 Meconium in the amniotic fluid not always show a fetal emergencies. If there is
meconium, observation the FHR to know signs of fetal emergenies (FHR< 100 or
FHR > 180 bpm).
c. Moulding

Moulding is an important indicator of how well the maternal pelvis accommodate

the fetal head. The overlapping of fetal bone head shows there is Cephalo Pelvic
Disproportion (CPD). The following key is used to record moulding:

0 : the sutures can be felt easily and the bones are separated
1 : the bones are just touching each other
2 : the bones are overlapping but can be separated easily with your finger
3 : the bones are overlapping and cannot be separated with your finger

3. PROGRESS OF LABOR7

Column and the second row is for recording partographs progress of labor.
Number 0 10 are listed at the edge of the left column is the amount of cervical
dilation. Each number/box indicates the extent of the cervical opening. One box with
another box in the lane indicating the addition of 1 cm dilated. Number scale 1 5
shows how much descent of the fetal head. Each box in this section stated period of
30 minutes.

1. The opening of the cervix, cervical dilation assessment and recording is done
every 4 hours or more often if there are signs of complications. When the
maternal is in the active phase of labor, the findings note on the partographs
symbol with X. this symbol should be written in accordance with the timeline
that the magnitude of the opening of the cervical column in the alert line. Connect
the X on each examination with a solid line.
2. Registration of a decrease in the lowest part or fetal presentation on every 4 hours,
or more often if there are signs of complications. The words Descent of the fetal
head and the unconnected line listed on the same side as the opening number of

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 the cervix. Give the sign - at the appropriate time line and connected with an
solid line.
3. Outline alert and action lines starts at the opening of the cervix alert 4 cm, and
ending at the point where a full opening, with expected opening rate of 1 cm per
hour. Recording during the active phase of labor should be initiated in alert line.

4. TIME7

Time of onset of the active phase of labor, at the bottom of the opening of the
cervix and descent, stmped boxes numbered 1 16. Each box represents one hour
since the start of the active phase of labor.

The actual time when the inspection is done, the box under the column for the
starting time of the active phase, indicated boxes to record the actual time when the
inspection is done. Each box represents a full hour and associated with two boxes of
30 minutes on the track lane above it or the contraction lane underneath. When the
maternal entered the active phase of labor, cervical dilation noted in the alert line.
Then record the actual time of this examination at the appropriate time box. As the
example, the recorded contractions in the lower row id a five-lane box with the
inscription contractions per 10 minutes on the outside of the most left column. Each
box represents one contraction. Every 30 minutes, touch and note the number of
contraction in seconds. Indicate the number of contractions that occur within 10
minutes of using the symbol:

: when contraction duration less than 20 seconds

: when contraction duration 20 to 40 seconds

: when contraction duration of more than 40 seconds.

5. DRUGS AND INTRAVENOUS FLUID 7

Drugs and IV fluids are given in the box below the observations lane. For each
oxytocin drip, must document every 30 minutes the amount of oxytocin is given per

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 unit volume of fluid (IV) and in units of droplets per minute, record all the additional
drugs or IV fluids.

6. MATERNAL CONDITION7

Maternal Condition written in the last section on the front sheet partographs
related to the health and comfort of the mother, include:

a. Pulse pressure, blood pressure and body temperature

The numbers on the left side of the partograph associated with maternal
pulse and blood pressure. Value and record maternal pulse every 30 minutes
during the active phase of labor, or more often if suspected complication using dot
symbol ( ). Recording of the maternals blood pressure every 4 hours during the
active phase of labor, or more often if suspected complication. The body
temperature recorded every 2 hours or more often if the body temperature rises or
perceived presence of infection in the appropriate box.
b. The volume of urine, protein or aceton
Measure and record the amount of urine production of maternal at least
every 2 hours (every time maternal urinate). If possible each time the
maternal urinate, check the presence of acetone or protein in urine.
7. CARE, OBSERVATION, AND CLINICAL DECISION 7
Record all other care, observation and clinical decision include:
a. Amount of fluid given orally
b. Headache or blurred vision
c. Consultation with other birth attendants
d. Preparation prior to referral
e. Referral Efforts

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Figure 20. Partograph form

30
 CHAPTER III

CONCLUSION

When doing the obstetric physical examination, first is to estimated date of

confinement using nageles rule, after that we can continue to measure the uterine size by
measured the fundal height with a tape from the top of the symphysis pubis, over the
uterine curve, to the top of the fundus, fetal weight which most examinations involve an
estimate of the height of the fundus uteri on the abdomen, not the length of the uterus,
fetal heart rate noting its rate (FHR), location, and rhythm, fetal heart tones.
Leopold maneuvers essential to determine the position of the fetus within the
uterus for labor management. This may be accomplished with the four maneuvers
described by Leopold for examination of the abdomen. The first maneuver determines
which fetal pole occupies the uterine fundus. The second maneuver, the lateral aspects of
the uterus are palpated to determine on which side the fetal back or fetal extremities, or
small parts are located. The third maneuver reveals what fetal part lies over the pelvic
inlet.The fourth maneuver reveals the presentation.
Presentation describes that part of the fetus that is lowest in the pelvis is the
vertex, the breech, or the shoulder and pelvic examination includes presence or absence
of perineal, vaginal, and cervical lesions (including herpes or human papilloma virus
infections), adequacy of the bony pelvis,Integrity of the fetal membranes,degree of
cervical dilation and effacement, station of the presenting part.
Partograph is use to record partograph observations and progress of labor and
birth process to know whether the process runs normally. Recording of the partograh
beginning of the active phase when the opening of the cervix. Observation starts from the
active phase, then information about the maternal, time of rupture of the membranes, fetal
condition (fetal heart rate, amniotic fluid,molasses), progress of labor (the opening of the
cervix, registration of a decrease in the lowest part or fetal presentation and outline alert
and action lines), time, uteric contraction, medication and maternal condition (vital signs,
and the volume of urine, protein or aceton) and care, observations and clinical decision.

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