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PARTOGRAM
The partogram provides a graphical
illustration of the progress of labour and
is considered by the World Health
Organisation (WHO) to be a valuable
tool for managing intrapartum women
 Studies, including a multicentre
randomised control trial involving 35,000
women, have shown improved maternal
and fetal outcomes with use of the
partogram.


Use of the partogram with its alert and
action lines – and an agreed upon
management protocol when these lines
are reached has been found to reduce
the incidence of prolonged labour,
augmentation, emergency caesarean
section and intrapartum stillbirth in both
nulliparous and multiparous women.
The partogram

All patients who present in active labour,
irrespective of place of delivery. The active
phase of labour commences at or after
4cm of cervical dilatation.

The partogram should be used for all
women admitted in established labour.
When the partogram is commenced at
the beginning of the induction process the
Alert and Action lines are drawn when
the women is in the active phase of
labour

Established labour is defined as the
presence of regular contractions,
increasing in strength and duration,
leading to progressive effacement and
dilatation of the cervix
A rate of 1cm/hour in the active phase of
labour is often accepted as normal
progress in labour.
 Many women who show slower rates of
cervical dilation will proceed to normal
birth

Completion of the Partogram
The four hourly ‘action and alert lines’
should be used to easily observe the
progress of labour
 The time and date should be entered
every 30 minutes using the 24 hour clock.
The hour should be documented on the
line of each square.
 Each hourly square should have fetal
heart recordings documented


The Alert line is a simple tool which
separates women into two groups:

Women with cervical dilatation equal to /
greater than 1cm/hour who are highly
unlikely to require operative intervention.

Women with cervical dilatation slower than
1 cm/hour who are more likely to require
operative intervention

The WHO partogram does not
differentiate between nulliparous or
multiparous women’s labours
Fetal observations

Auscultation of the fetal heart rate should
be recorded in the fetal heart rate section
of the partogram and documented every
15 minutes. It is recorded on the graph by
•.and each dot be linked by a line

During the second stage of labour the
fetal heart is recorded every 5 minutes of
the labour care records. The recordings
on the partogram are to continue quarter
hourly on the fetal heart rate section
Maternal observations should
include a minimum of

• 4 hourly temperature, blood pressure, respirations and pulse rate documented within
the MEOWS chart including the MEOWS score

• Additional hourly pulse rate

• Half hourly documentation of the frequency of contractions

• Aim to empty the bladder within every four hours and document urinalysis

• Vaginal examination should be offered four hourly

• Ensure adequate levels of hydration are maintained

• Assess need for analgesia continuously

• Amniotic fluid to be recorded hourly
Liquor - the presence or absence of liquor
should be marked in the appropriate space, using
letter symbols,

• I = Intact membranes

• C= Clear liquor

• M = Meconium stained liquor

• BS = Blood stained liquor

• A = An absence of liquor

Molding of the fetal skull bones is an
important indication of how adequately the
pelvis can accommodate the fetal head. An
increase in molding with the fetal head high
in the pelvis is an ominous sign of pelvic
disproportion. Molding should be marked on
the partogram as

• Present

• Not Present
Definitions of the degree of molding will be
highlighted within the maternal labour care
records within the vaginal examination
sticker. These will be circled upon
completion of the vaginal examination and
are referenced as followed
 0 = Separated bones, sutures felt easily
 + = Bones just touching each other
 ++ = Overlapping bones, reducible
 +++ = Severely overlapping bones, non
reducible


Completing the Cervicograph - The
cervicograph is the section of the
partogram which depicts cervical
dilatation and descent of the presenting
part in relation to time. Use of the
cervicograph enables the progress of
labour to be ascertained and delay in the
progress readily recognised

Within the cerviograph cervical dilatation
and descent should be documented by
plotting on the chart; cervical dilatation
should be marked every four hours by an
X, marking in the appropriate time space
when the examination is performed. A
line should then be drawn between the
appropriate markings using a straight
edged ruler.



Descent of the head is measured during the
same vaginal examination. It is expressed in
terms of descent of the fetal head in relation
to the Ischial spines.
It is recorded on the graph by a •.
This denotes the level of descent at each
vaginal examination which will correspond
to the cervical dilatation symbol. As the
cervical dilatation increases and descent of
the head occurs the plotted lines will meet
The Alert and Action Lines
Parallel lines are to be drawn on the partogram at the
time of the first vaginal examination in active labour
or prior to/following commencement of syntocinon.
 The alert lines are different for a primigravida and a
multigravida. We would anticipate a primigravida to
dilate ½ cm an hour and for a multigravida to dilate
1cm per hour from 4cm dilated.
 Multigravida: The alert is drawn from the point of
cervical dilatation noted at the first vaginal
examination.
 Primigravida: The alert is drawn 4 hours to the
right of the point of cervical dilatation noted at the
first vaginal examination.


If the plotted dilatation of the cervix moves to
the right of the alert line this may denote a
prolonged labour which then requires immediate
action i.e. an amniotomy and vaginal reassessment
2 hours later.
 The action line is a parallel line which is plotted
4 hours to the right of the alert line. If the plotted
dilatation of the cervix moves to the right of the
alert line and crosses the action line (after
amniotomy and review) this denotes a prolonged
labour which requires immediate referral to the
obstetric registrar on call for obstetric review
and active management.







Drugs and fluids should be recorded as
indicated on the partogram.
The midwife should ensure that she initials the
partogram hourly as indicated.
Contractions
Observe and record the number of contractions
palpated every 30 minutes in the active phase.
Each square on the partogram measures one
contraction.
Palpate and note the number of contractions
made in 10 minutes and the duration of the
contraction in seconds (time from when the first
contraction is palpated until it phases away)
Documentation
Ensure that all recordings and findings are
accurately and legibly recorded in the patient’s
handheld records and onto any formal charts,
such as prescription charts, intravenous additive
charts and cardiotocograph.
 The midwife should document the date and time
of the commencement of the partogram.
 On completion of the partogram, the midwife
must complete the chart by recording the time,
date, sex and method of delivery at the end of the
partogram

Infection Prevention
 All staff should follow Trust guidelines on
infection prevention by ensuring that they
 effectively ‘decontaminate their hands’
before and after each procedure.
 Audit and Monitoring


As a minimum the following specific
requirements will be monitored:

• Documentation of observations in labour

• Process for audit, multi-disciplinary review
of audit results and subsequent monitoring
of action plans

Enter all details in the appropriate
sections on the front of the partogram,
including date, gravidity, parity, EDD,
gestation, date and time of
commencement of labour and date, time
and mode of rupture of membranes.
Include age, blood group, weight, any
relevant obstetric & medical history,
present pregnancy, risk factors, allergies
and group B streptococcus status
MATERNAL ASSESSMENT

Record maternal blood pressure, pulse, temperature,
respirations, and other observations (eg reflexes, blood sugar
levels) on the graph at the top of the partogram.

Using the measurements down the left side of the graph
record:

Systolic blood pressure with a Λ

Diastolic blood pressure with a V

Pulse with a •
LABOUR ASSESSMENT
Contractions
Descent
Descent of the head is measured by
abdominal palpation and is expressed in
terms of fifths above the pelvic brim.
Record O for the level of descent at each
vaginal examination.
 At 0/5, the sinciput is at the level of the
symphysis pubis.

Management

A vaginal examination is performed 4 hours after
the initial one or earlier if clinically warranted.

If subsequent examination shows dilatation
between Alert line and Action line a repeat vaginal
examination is carried out in 2 hours.

At this examination if the cervical dilatation is
touching / crossing the Action line, the Labour
and Birth Suite medical team must evaluate the
woman’s progress in labour and instigate
appropriate intervention.
INTRAPARTUM
MEDICATIONS

Epidural

Draw an arrow to indicate the time of epidural insertion and
subsequent medications administered.

Epidural medication administration details must also be recorded
on the MR280.

Other medications

In the box provided, write the name, dose and route of
administration of medication. Draw an upwards arrow along the
page to indicate the correct time of administration.

Medications must also be recorded on the Medication Chart
MR810.
FLUID BALANCE

INPUT
Oral fluids

Record type and volume in mL.

IV Fluids

When an intravenous infusion is commenced record the fluid type, total volume and any
medication added (e.g. Syntocinon).

Record the commencement time with an arrow along the time lines.

When complete, record the total volume infused in the appropriate time box. When
bag/pack is completed and infusion is to be maintained, record another arrow at
commencement time.

Where a record of input fluid volume is required hourly (e.g. in patients with
known risk factors such as pre-eclampsia), a progressive volume total may also
be documented

OUTPUT

Urine

Measure and record the volume of urine (if required) or document PUIT for each void.

Record urinalysis (if required) for protein and ketones in the appropriate time box.

Vomitus

Record volume in mL in the appropriate time box.

Blood loss

Record volume in mL in appropriate time box.

Blood loss should be weighed.Weigh the pad, incontinence sheet, etc, then subtract the
weight of a dry pad, incontinence sheet, etc, to give the amount of total blood loss.
VAGINAL EXAMINATIONS

Date/time

Record for each examination.

Indication

Specify the reason for the vaginal examination e.g. to assess progress of
labour, apply FSE.

Cervical Effacement/length

Estimate length in cm.

Dilatation

Measured dilatation in cm.
‫اجزاء پارتوگرام‬
‫به ترتیب ذیل میباشد‪:‬‬
‫‪ – 1‬وضعیت سالمتی جنین‬
‫ضربان قلب جنین‬
‫پرده های جنینی و مایع آمنیوتیک‬
‫مولدینگ سرجنین‬
‫‪ ‬پیشرفت زایمان‬
‫‪ ‬اتساع دهانه رحم‬
‫‪ ‬نزول سر جنین لمس شکمی پنج‬
‫قسمتی سرجنین که در باالی مدخل لگن‬
‫‪ ‬احساس میشود‬
‫‪ ‬انقباضات رحم‪:‬‬
‫‪ - ‬تکرار طی ده دقیقه‬
‫‪ - ‬زمان (به وسیله سایه های مختلف نشان‬
‫بر روی پارتوگراف زیر خط مربوط به‬
‫زمان ‪ 5‬خانه با خطوط سایه زده شده وجود‬
‫دارد که از طول پارتوگراف میگذرد و در‬
‫سمت چپ این خانه ها‪ ،‬تعداد انقباضات در ‪10‬‬
‫دقیقه نوشته شده است‪ .‬هر خانه نمایانگرانقباض است‪،‬‬
‫بنابراین اگر طی ‪ 10‬دقیقه ‪2‬‬
‫انقباض وجود داشته باشد‪ ،‬دو خانه سایه زده‬
‫میشود‪.‬‬
‫وضعیت سالمتی مادر‬
‫نبض‪ ،‬فشارخون و درجه حرارت‬
‫ادرار از نظر مقدار‪ ،‬پروتئین و استون‬
‫استفاده از اکسی توسین‬
‫داروهای تجویز شده و مایعات‬
‫وریدی‬
‫اصول پارتوگرام‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪‬‬
‫‪ – 1‬مرحله نهفته کمتر از ‪ 8‬ساعت طول‬
‫میکشد‪.‬‬
‫‪ – 2‬مرحله فعال از دیالتاسیون ‪3‬سانتیمتر شروع شده و فاصلهای ‪ 4‬ساعته از‬
‫کاهش سرعت زایمان تا نیاز به مداخالت‬
‫(فاصله بین خط هشدار ‪ 2‬و خط عمل ‪ )3‬وجود‬
‫دارد‪.‬‬
‫‪ – 3‬در طول مرحله فعال سرعت‬
‫دیالتاسیون دهانه رحم نباید کمتر از‬
‫‪1‬سانتیمتر در ساعت باشد‪.‬‬
‫‪ – 4‬توشه واژینال جزء کلیدی اداره زایمان‬
‫و رسم پارتوگراف است که هر ‪4‬ساعت یک بار‬
‫انجام میشود‪ .‬بنابراین در هر زایمان بیش از‬
‫‪ 3-2‬توشه نیاز نیست (در مواردی که زایمان‬
‫‪10- 7‬سانتیمتر ‪ -‬قریب الوقوع است‪ ،‬در فواصل کمتری انجام میشود)‪.‬‬
‫اگر منحنی دیالتاسیون دهانه رحم زائو‪ ،‬در سمت چپ پارتوگرام یا روی خط‬
‫هشدار باشد‪ ،‬پیشرفت زایمان طبیعی تلقی‬
‫میشود‪.‬‬
‫– گاهی خطوطی پیش از خطوط هشدارو عمل رسم میشود که نشان زمان‬
‫‪ (.‬تصمیمگیری میباشد‬
‫– خط عمل به موازات خط هشدار به فاصله ‪ 4‬سانتیمتری از آن رسم میشود‪ .‬در‬
‫صورت وجود خط دیالتاسیون در سمت راست خط هشدار در روی منحنی‬
‫پارتوگرام‪ ،‬انتقال زائو از مرکز تسهیالت به بیمارستان ضروریاست ولی اگر‬
‫منحنی دیالتاسیون‪ ،‬خط عمل را روی نمودار قطع کند‪ ،‬پیشرفت زایمان بسیار‬
‫کند و خطرناک بوده و ارزشیابی فوری درمورد وضع زائو و مقابله با تأخیر‬
‫زایمان الزامی است‬