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The WHO partograph

See World Health Organization (2008) Managing Prolonged and Obstructed Labour (http://whqlibdoc.who.int/publications/2008/9789241546669_4_eng.pdf).

The partograph is a graphic record of the progress of labour and relevant details of the mother and fetus. It was initially introduced as an early warning system to detect labour that was not progressing normally. This would allow for timely transfer to occur to a referral centre, for augmentation or Caesarean section as required. The partograph indicates when augmentation is needed, and can point to possible cephalopelvic disproportion before labour becomes obstructed.

It increases the quality and regularity of observations made on the mother and fetus, and it also serves as a one-page visual summary of the relevant details of labour. The partograph has been used in a number of countries, and has been shown to be effective in preventing prolonged labour, in reducing operative intervention, and in improving the neonatal outcome.

It is important to ensure that adequate supplies of the form are always available.

The WHO partograph begins only in the active phase of labour, when the cervix is 4 cm or more dilated (see below). However, it is a tool which is only as good as the health-care professional who is using it. The observations that are recorded will document the following:

O Maternal well-being: record pulse rate every 30 minutes, blood pressure and temperature 4-hourly, urine output and dipstick testing for protein, ketones (if available) and glucose after voiding, and record all fluids and drugs administered. If the findings become abnormal, increased frequency of observation and testing will be required, and intervention may be implemented.

O Fetal well-being: record fetal heart rate for 1 minute every 15–30 minutes after a contraction in the first stage, and every 5 minutes in the second stage. If abnormalities are noted, urgent delivery can be considered.

O Liquor: clear, meconium stained (thick or thin), bloody or absent. Thick meconium suggests fetal distress, and closer monitoring of the fetus is indicated. Check every 30 minutes.

O Frequency, duration and strength of uterine contractions (assessed by palpation): record every 30 minutes.

O Abdominal examination: to assess descent of the fetal head.


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FIGURE 2.3.7 The modified WHO partogram without latent phase.


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FIGURE 2.3.9 How to record contraction frequency and length. The number of squares filled in records the number of contractions in 10 minutes. The shading shows the length of contractions.

O Vaginal examination: this should be done no less than every 4 hours to assess cervical dilatation, descent of the fetal head, and moulding of skull bones. More frequent examination is only undertaken if indicated.


There must be a team approach, and senior staff must oversee the care of high-risk patients. Ideally there should be one-to one care.


Key to partogram

O Amniotic fluid: I = membranes intact, C = membranes ruptured, clear fluid, M = meconium-stained fluid, B = bloodstained fluid.


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FIGURE 2.3.8 Sample partogram showing normal progression of labour.


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FIGURE 2.3.10 Recording effacement: the length of the cervix. Effacement can be recorded by thickening a line with a pen as shown in the diagram, or ‘percentage’ effacement can be written in the squares.


O Moulding: 0 = bones are separated and sutures can be easily felt; + 1 = bones are just touching each other; + 2 = bones are overlapping but can be reduced; + 3 = bones are severely overlapping and irreducible.

O Cervical dilatation: assess at each VE and mark with a cross ×. Begin at 4 cm.

O Alert line: starting at 4 cm of cervical dilatation, up to the point of expected full dilatation at the rate of 1 cm per hour.

O Action line: parallel and 4 hours to the right of the alert line.

O Descent assessed by abdominal palpation: this refers to the part of the head (which is divided into five parts) palpable above the symphysis pubis; recorded as a circle (O) at every vaginal examination. At 0/5, the sinciput (S) is at the level of the symphysis pubis.

O Hours: this refers to the time elapsed since the onset of the active phase of labour (observed or extrapolated).

O Time: record the actual time at 30-minute intervals.

O Contractions: chart every 30 minutes; palpate the number of contractions in 10 minutes and their duration in seconds (< 20 seconds, 20–40 seconds, > 40 seconds).

O Oxytocin: record the amount (in units) of oxytocin per volume of IV fluids, and the number of drops per minute, every 30 minutes when used.

O Drugs given: record any additional drugs given.

O Pulse: record every 30 minutes and mark with a dot (•). O Blood pressure: record every 4 hours and mark with arrows, unless the patient has a hypertensive disorder or pre-eclampsia, in which case record every 30 minutes.

O Temperature: record every 4 hours.

O Urine, ketones and volume: ideally record every time urine is passed.


 

Maternal condition
Fetal condition
Membranes and liquor
Moulding of fetal skull bones (see Figure 2.3.11)

  

 

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