Presentation on monitoring of labour using a partograph in Tanzania

1. MONITORING THE PROGRESS OF LABOUR
Beata Mushema MD, MSc
July 2023

2. SESSION OBJECTIVES
By the end of this session, you should be able to:
1. Describe the uses and value of partograph
2. Describe the main parts of a partograph
3. Describe the indicators in a partograph that
show good progress of labour, and signs of
fetal and maternal wellbeing
4. Plot and interpret a partograph (composite
and modified)

3. INTRODUCTION
• More than one third of maternal deaths, half
of stillbirths and a quarter of neonatal deaths
result from complications during labour and
childbirth.
• Monitoring of labour and childbirth, and early
identification and treatment of complications
are critical for preventing adverse birth
outcomes.

4. PARTOGRAPH
• The partograph is a graphical presentation of
the progress of labour, and of fetal and
maternal condition during labour.
• It is the best tool to help you detect whether
labour is progressing normally or abnormally,
and to warn you as soon as possible if there
are signs of fetal distress or if the mother’s
vital signs deviate from the normal range.

5. EVOLUTION OF THE
PARTOGRAPH

6. EVOLUTION OF THE PARTOGRAPH
(FRIEDMAN)
• Emanuel Friedman established criteria for the
normal progress of labor in the 1950s.
• He conducted his studies defining the
spectrum of normal labor by evaluating the
course of labor of different women.
• He observed that normal labor should
progress at a rate of at least 1 cm cervical
dilatation per hour, starting at 3 to 4 cm of
dilatation.

7. EVOLUTION OF THE PARTOGRAPH
(FRIEDMAN)
• Friedman divided labour functionally into two
parts:
– The (early) latent phase extends over 8-10 hours
and up to about 3 cm dilation.
– This was followed by an active phase,
characterized by acceleration from about 3-10 cm
at the end of which deceleration occurred.
• This work has been the foundation on which
others have built.

10. EVOLUTION OF THE PARTOGRAPH
(PHILPOTT AND CASTLE)
• In the 1960’s Philpott proposed the use of a graph to
represent the progress of labour with the primary aim
to identify abnormal progress.
• Philpott and Castle developed the first partograph, by
utilizing Friedman's cervicograph, and adding the
relationship of the presenting part to maternal pelvis
on their graph as a means to assess labour progress.
• Philpott devised a key for assessing and documenting
uterine contractions over a 10 - minute period. This
was also added to the partograph format to aid in the
assessment of labour progress.

11. EVOLUTION OF THE PARTOGRAPH
(PHILPOTT AND CASTLE)
• As well as assessing the progress of labour,
Philpott added an assessment of foetal
condition by devising a system of foetal heart
rate grading, and a scale for assessing the
presence of caput and moulding as a means of
detecting degrees of cephalopelvic
disproportion.

12. EVOLUTION OF THE PARTOGRAPH
(PHILPOTT AND CASTLE)
• In the 1970’s Philpott and Castle researched their
partograph in the management of labour in primigravid
women in Rhodesia (Zimbabwe).
• From this research, and their aims to identify abnormal
labour and reduce mortality rates, they added action
and alert lines and other intrapartum details to their
cervicographs to complete the partograph.
• Alert and action lines were added to identify "at risk"
labouring women who would need transfer from rural
centers to specialized units for active management of
their labour.

13. EVOLUTION OF THE PARTOGRAPH
(WHO)
• In 1987 the Safe Motherhood
conference was held in Nairobi, and
as a part of the Safe Motherhood
Initiative the WHO revised,
approved, and promoted the
universal use of the partograph with
view to reducing maternal and fetal
mortality.

14. EVOLUTION OF THE PARTOGRAPH
(WHO COMPOSITE PARTOGRAPH)
• The first WHO partograph or ‘Composite
partograph’, covers a latent phase of
labour of up to 8 hours and an active
phase beginning when the cervical
dilatation reaches 3 cm.
• The active phase is depicted with an alert
line and an action line, drawn 4 hours
apart on the partograph.

16. EVOLUTION OF THE PARTOGRAPH
(WHO MODIFIED PARTOGRAPH)
• Since a prolonged latent phase is relatively infrequent
and not usually associated with poor perinatal
outcome, the usefulness of recording the latent phase
of labour in the partograph has been questioned.
• Moreover, differentiating the latent phase from false
labour is often difficult.
• To alleviate these disadvantages, a modified WHO
partograph was introduced and incorporated removal
of the latent phase and defined the beginning of the
active phase at 4 cm cervical dilatation instead of 3 cm.

17. Modified WHO partograph

18. WHO LABOUR CARE GUIDE (2020)
• User-friendly design
• New start of active phase
• Supportive care (birthing position,
companion, pain relief, oral fluids)
• Shared decision making
• Alert thresholds

19. WHEN TO START A PARTOGRAPH
• In current practice, a partograph is started
when a women is in active phase of the first
stage of labour (starting at 4cm).
• It should be used during the process of labour
and not plotted after delivery.
• Personal information including name, gravida,
para, registration/hospital number, date and
time of admission, time of ruptured
membranes is written at the top of the graph.

20. MAIN COMPONENTS OF THE
PARTOGRAPH
Foetal condition
Progress of labour
Maternal condition

21. FOETAL CONDITION

22. Foetal Heart Rate
 This is recorded half-hourly to
monitor the condition of the fetus.
 Plotted with a dot .
 Normal range 120-160bpm (WHO)

25. Liquor
• Amniotic fluid is observed and recorded
at each vaginal examination as follows:
 I – the membranes intact
 C – clear amniotic fluid
 В – blood-stained amniotic fluid
 M – meconium-stained amniotic fluid
 A – absent amniotic fluid

26. Moulding
• The bones of the fetal head can move
closer together or overlap to help the
head fit through the pelvis. Parietal
bones overlap occipital and frontal
bones.
• Moulding is assessed and recorded at
each vaginal examination as follows:

27. Degrees of Moulding
• If parietal bones are separated and the
sutures can be felt easily: record as “0".
• If parietal bones are just touching each other:
record as “+” or “+1)
• If parietal bones are overlapped but easily
reduced with digital pressure: record as “++”
or “+2)
• If parietal bones have overlapped and are
irreducible. reduced: record as “+++” or “+3)

28. Degrees of Moulding

29. Moulding
• Up to 2+ moulding may be normal in
the later stages of labour.
• Severe moulding (3+) is a sign of
obstruction.

30. PROGRESS OF LABOUR

31. Cervical dilatation
• This is the most important observation to
monitor progress of labour. Cervical
dilatation is assessed at every vaginal
examination (every 4 hours)
• Cervical dilatation is plotted with: X

32. Descent
• Descent assessed by abdominal palpation
refers to the part of the head (divided into
5 parts) palpable above the symphysis
pubis. It is assessed every 4 hours.
• Descent is plotted with: O

34. Contractions
Less than 20 seconds
20-40 seconds
More than 40 seconds
Contractions are recorded every 30 minutes; palpate the
number of contractions in 10 minutes and their duration in
seconds.

35. MATERNAL CONDITION

36. Maternal condition
• Oxytocin, drugs and intravenous fluids if given are
recorded in the spaces provided.
• Pulse (plotted with dots on the partograph)
should be taken every 30 minutes
• Blood pressure (reported by a line between
systolic and diastolic pressure values) and
temperature – every 4 hours (or more often, if
necessary)
• Record amount of urine passed every 2-4 hours
• The urine should be tested for protein and
acetone, if indicated

37. PARTOGRAPH EXERCISES
Plot and interpret the partographs of
the following women

38. CASE 1
Maria R. G4P3, admitted on 16/02/2023 at 22:00hrs (Hospital
number 345836)
• Fetal heart rate - 136 beats / min
• Amniotic fluid – intact
• No moulding
• Cervical dilatation – 4 cm
• Head descent - 4/5
• 3 contractions in 10 min each less than 20 seconds
• Blood pressure – 120/70mmHg
• Pulse – 70 beats /min
• Temperature – 36.4 ºC
• Urine – 90 ml

39. Fetal heart rate
• 22:30 - 140 beats / min,
• 23:00 - 150 beats / min,
• 23:30 - 140 beats / min,
• 00:00 - 130 beats / min,
• 00:30 - 140 beats / min,
• 01:00 - 146 beats / min,
• 01:30 - 132 beats / min,
CASE 1

40. Uterine contractions
• 22:30 - 3 contractions lasting less than 20 seconds,
• 23:00 - 3 contractions lasting 30 seconds,
• 23:30 - 3 contractions lasting 35 seconds,
• 00:00 - 3 contractions lasting 40 seconds,
• 00:30 - 4 contractions lasting more than 40 seconds,
• 01:00 - 4 contractions lasting more than 40 seconds
• 01:30 - 4 contractions lasting more than 40 seconds
CASE 1

41. Maternal Pulse
• 22:30 - 80 beats / min,
• 23:00 - 80 beats / min,
• 23:30 - 90 beats / min,
• 00:00 - 90 beats / min,
• 00:30 - 90 beats / min,
• 01:00 - 80 beats / min,
• 01:30 - 80 beats / min,
CASE 1

42. CASE 1
At 02:00
• Fetal heart rate - 140 beats / min
• Amniotic fluid – clear
• Fetal bones slightly overlap but are reducible
• Cervical dilatation – 8 cm
• Head descent - 2/5
• 4 contractions in 10 mins lasting more than 40 seconds
• Blood pressure – 125/80mmHg
• Pulse – 82 beats /min
• Temperature – 36.7 ºC
• Urine – 140 ml

43. At 02:50 she delivered by SVD a live male,
BWT 3600g
CASE 1

44. Helena M. G3P2 02/03/2023 at 09:00 (Hospital number 986843)
• Fetal heart rate – 132 beats /min
• Amniotic fluid – intact
• Head moulding – no
• Cervical dilatation – 2 cm
• Head descent – 5/5
• Contractions in 10 min – 2 contractions each lasts 25 seconds
• Blood pressure – 140/80
• Pulse – 80 beats /min
• Temperature – 36.4 ºC
• Urine – 120 ml
CASE 2

45. CASE 2
At 13:00
• Fetal heart rate – 140 beats /min
• Amniotic fluid – clear
• Head moulding – no
• Cervical dilatation – 5 cm
• Head descent – 4/5
• Contractions in 10 min – 3 contractions each lasts 35
seconds
• Blood pressure – 135/80
• Pulse – 82 beats /min
• Temperature – 36.4 ºC
• Urine – 150 ml

46. CASE 2
Fetal heart rate
• 13:30 - 140 beats / min,
• 14:00 - 150 beats / min,
• 14:30 - 130 beats / min,
• 15:00 - 130 beats / min,
• 15:30 - 140 beats / min,

47. CASE 2
Contractions per 10 minutes
• 13:30 - 3 contractions each lasts 35 seconds,
• 14:00 - 3 contractions each lasts 40 seconds,
• 14:30 - 3 contractions each lasts 50 seconds,
• 15:00 - 4 contractions each lasts 55 seconds,
• 15:30 - 4 contractions each lasts 55 seconds,

48. CASE 2
Maternal Pulse
• 13:30 - 80 beats / min,
• 14:00 - 80 beats / min,
• 14:30 - 90 beats / min,
• 15:00 - 90 beats / min,
• 15:30 - 90 beats / min,

49. CASE 2
At 16:00
• Fetal heart rate – 146 beats /min
• Amniotic fluid – clear
• Head moulding – the bones slightly overlap but are
reducible
• Cervical dilatation – 9 cm
• Head descent – 1/5
• Contractions in 10 min – 4 contractions each lasts 55
seconds
• Blood pressure – 140/80
• Pulse – 88 beats /min

50. CASE 2
• At 1645hrs she spontaneously delivered a live
female with birth weight of 3800g

51. CASE 3
• Elena Richard a 26-year-old pregnant woman at
38 weeks and 2 days gestation was admitted to
the antenatal ward yesterday at 0400hrs,
presenting with labour-like pains.
• This is her second pregnancy; her last child was
delivered 3 years ago with a birth weight of 2.8kg
and is alive.
• Her hospital number is 5657652. The following
are her examination findings during admission

52. CASE 3
On admission:
• Fetal heart rate – 130 beats /min
• Amniotic fluid – clear
• Head moulding – no
• Cervical dilatation – 2 cm
• Head descent – 4/5
• Contractions in 10 min – 2 contractions each lasts 20 seconds
• Blood pressure – 110/70mmHg
• Pulse – 68 beats /min
• Temperature – 37.5 ºC

53. CASE 3
At 0600hrs
• Fetal heart rate – 136 beats /min
• Amniotic fluid – clear
• Head moulding – no
• Cervical dilatation – 4 cm
• Head descent – 4/5
• Contractions in 10 min – 3 contractions each lasts 40 seconds
• Blood pressure – 115/75mmHg
• Pulse – 70 beats /min
• Temperature – 36.7 ºC
• Urine- 120ml; NEG for Protein and Acetone

54. CASE 3
Fetal heart rate
• 0630hrs - 136 beats / min,
• 0700hrs - 138 beats / min,
• 0730hrs - 150 beats / min,
• 0800hrs- 150 beats / min,
• 0830hrs - 140 beats / min,
• 0900hrs – 130 beats / min,
• 0930hrs - 140 beats / min,

55. CASE 3
Uterine contractions
• 0630hrs - 3 in 10 mins; lasting 40 seconds
• 0700hrs - 3 in 10 mins; lasting 40 seconds,
• 0730hrs - 3 in 10 mins; lasting 40 seconds,
• 0800hrs- 3 in 10 mins; lasting 45 seconds,
• 0830hrs - 3 in 10 mins; lasting 45 seconds,
• 0900hrs – 4 in 10 mins; lasting 45 seconds,
• 0930hrs - 4 in 10 mins; lasting 45 seconds,

56. CASE 3
Maternal Pulse
• 0630hrs - 80 beats / min,
• 0700hrs – 80 beats / min,
• 0730hrs - 90 beats / min,
• 0800hrs- 90 beats / min,
• 0830hrs - 90 beats / min,
• 0900hrs – 80 beats / min,
• 0930hrs - 80 beats / min,

57. CASE 3
At 1000hrs
• Fetal heart rate – 140 beats /min
• Amniotic fluid – clear
• Head moulding – Parietal bones are just touching each other
• Cervical dilatation – 6 cm
• Head descent – 3/5
• Contractions in 10 min – 4 in 10 mins; lasting 50 seconds
• Blood pressure – 115/80mmHg
• Pulse – 85 beats /min
• Temperature – 36.6 ºC
• Urine- 100ml; NEG for Protein and Acetone

58. CASE 3
Fetal heart rate
• 1030hrs - 130 beats / min,
• 1100hrs - 140 beats / min,
• 1130hrs - 120 beats / min,

59. CASE 3
Uterine contractions
• 1030hrs - 4 in 10 mins; lasting 45 seconds,
• 1100hrs - 4 in 10 mins; lasting 55 seconds,
• 1130hrs - 4 in 10 mins; lasting 55 seconds,

60. CASE 3
Maternal Pulse
• 1030hrs - 80 beats / min,
• 1100hrs - 90 beats / min,
• 1130hrs - 100 beats / min,

61. CASE 3
At 1200hrs
• Fetal heart rate – 100 beats /min
• Amniotic fluid – meconium-stained
• Head moulding – Bones overlap and are not reducible
• Cervical dilatation – 6 cm
• Head descent – 3/5
• Contractions in 10 min – 4 in 10 mins; lasting 55 seconds
• Blood pressure – 140/90mmHg
• Pulse – 100 beats /min
• Temperature – 36.7 ºC
• Urine- 100ml; NEG for Protein and Acetone

62. CASE 3
At 1225, she delivered by emergency
caesarean section, a live female baby
with a birth weight of 4500g and
Apgar score 7-8.

63. REFERENCES
• Emanuel A. Friedman. Graphic Analysis of Labor.
ResearchGate. January 6, 2011. Available
at: https://www.researchgate.net/publication/229994697_Grap
hic_Analysis_of_Labor
• R. H. Philpott, W. Castle. CERVICOGRAPHS IN THE
MANAGEMENT OF LABOUR IN PRIMIGRAVIDAE.
Published in July 1972. Available
at: https://www.semanticscholar.org/paper/CERVICOGRAPHS
-IN-THE-MANAGEMENT-OF-LABOUR-IN-Philpott-
Castle/de7d90cdea0c15410e55fae44f48815c1db0f6a1
• WHO Pregnancy, childbirth, postpartum and newborn care: a guide
for essential practice – 3rd ed; 2015
• WHO recommendations: intrapartum care for a positive childbirth
experience. Geneva: World Health Organization; 2018
• WHO labour care guide: user’s manual. Geneva: World Health
Organization; 2020.

64. Thank you!
Mobile: +255 756 561 536
Email: beata.mushema@hkmu.ac.tz
Office: Level 6, Room 614